Category: Palliative Care

Palliative care, also known as comfort care is a significant care given to people with critical illnesses (Lugton & McIntyre, 1). It prolongs their life and relieve from pain affecting them and their intimates. Its goal is to prevent the symptoms and side effects of an illness besides treatment as early as possible. Palliative care is usually given systematically, putting into consideration psychosocial and spiritual needs of the patient and family. Routine for administration of palliative care should be provided by health care professionals.

The complexity of the situation usually determines if the condition is to proceed to palliative care. It begins from the time of diagnosis of life endangering illness and will continue until death and family grief period. It involves helping the patient relieve the suffering and making their families understand the conditions for change in patient. The effects of these changes should be made clear to them, and this will assist in the future care.

For this succeed, attention is required together with exceptional communication skills. Health professionals should pursue an illness from its early stages of diagnosis to prevent it from advancing. A complex diagnosis proceeds to palliative care (Meie, Isaacs & Hughes, 141). The basic elements of palliative care are pain, and symptom assessment and advanced care planning management.

Palliative care specialists should have the necessary competence in handling disagreement cases (Lugton & McIntyre, 3). In some of them, they are supposed to make decisions on whether to agree with the patients opinions or their own opinions (Meie, Isaacs & Hughes, 297). In such cases, the decision taken by the specialist depends on his/her competence. The decision starts from the point where a chronic case is to proceed to palliative care.

Usually, disagreement occurs between them and patients on whether cases will proceed to palliative care or aggressive treatment. Both parties should be able to reach a consensus, with the decision provided by the patient voluntarily. However, there are some cases where there is disagreement, and in such cases, the physician should balance the expected benefits with the risks of patients choice as compared to other alternatives.

In most cases, the physician is the decision maker due to patients, failure to make the right decision under that prevailing condition. The decision to be taken by the specialist should depend on the competency of the patient and values at stake (Meie, Isaacs & Hughes, 207). These values underlying standards of competence are promotion of individual well being of the patient and respecting their self determination.

Treatment should be stopped when the condition of the patient is complicated and irreversible. Advancement to palliative care can also occur if the treatment given to the patient is not working and causes a lot of pain to the patient. It can start immediately after the diagnosis of the condition. This implies that palliative care can be provided together with the treatment.

Decision on whether to offer palliative care should be done by both the clinician and the patient. They should be able to agree on such cases. If the patient is not able to make that decision, then it becomes the role of the clinician to do so. In some cases, a family member may demand for aggressive treatment to be given to the patient or may disagree among themselves (Hallenbeck, 163).

The ability to resolve such Medicare conflicts depends on the clinicians competency. An effort should be made towards enabling the families understand the suffering inflicted on the patient. Aggressive treatment could be causing a lot of pain on the patient.

This raises a concern on the need to review health care policy and ethics. It is evident in Schiavos case, which had a conflict between her husband and health professionals (Meie, Isaacs & Hughes, 179). The doctors obligation here is to help Schiavo from suffering, but her intimate feels as the doctor had neglected her. Other cases include Emilio Gonzales case, Hengla Wanglies case and Baby Ls case (Truog, 1).

These are few examples of futility cases, which involve disagreements and mistrust between clinician, and patients families. The success of a professional resolving such cases depend on communication skills and conflict resolution skills possessed by the physician (Lugton & McIntyre, 6). The obligation of the physician is to serve the interests of the patient and family equally (Lugton & McIntyre, 12). It is recommended that such ethical dilemmas involve hospital ethical committee.

Palliative care does not have a distinct payment insurance benefit. Usually, the cost of palliative care is covered with patients health insurance. The patients family members may be required to cover up the extra costs. Insurance programs have aided many people in payment of palliative costs.

People should be educated on the importance of joining them. In cases where a person is undergoing palliative care, it is the responsibility of community members to provide support to their family in terms of payment for premiums and psychosocially. It is also their responsibility to demand insurance programs to provide cover during palliative care.

Works Cited

Hallenbeck, James. Palliative Care Perspectives. London: Oxford University Press, 2003. Print.

Lugton, Jean & McIntyre, Rosemary. Palliative Care: The Nursing Role. California: Elsevier Health Sciences, 2005.Print.

Meie, Diane E., Isaacs, Stephen L. & Hughes, Robert. Palliative Care: Transforming the Care of Serious Illness. London: John Wiley & Sons, 2010. Print.

Truog, Robert. D. Tackling Medical Futility. N Engl J Med. Web. 357; 1-3.

Introduction

Palliative care entails satisfying the bodily, rational, and social demands of patients or caregivers. It improves patients livelihood and ability to recover. This care applies to persons experiencing challenges related to life-threatening conditions. The objective is to prevent or reduce suffering through prompt recognition, perfect examination and management of pain (Twycross, 2003). Management of diverse problems such as physical, mental or spiritual is inclusive of this phenomenon. A time comes when a patient develops a disease that leads to death. However, with excellent clinical care, the suffering reduces due to assessment of symptoms and assistance. The care offers pain relief, improves livelihood, and presents death as a normal stage. In addition, its objective is not to accelerate or delay death. Through palliative care, there is integration of both the mental and spiritual needs of patients. Additionally, an assistance system exists that enables patients to lead an active life (Mitchell, 2008). Moreover, there is application of team strategy in addressing the demands of patients or families. The result is an enhanced livelihood and manipulation of the disease. This is applicable in addressing the disease through varied therapies. Procedures such as chemotherapy and radiotherapy eventually manage these conditions. This paper describes palliative care and affiliated services offered within an Aged Facility Care. Furthermore, it describes the main beneficiaries such as the elderly persons suffering from dementia, Alzheimer and Parkinsons complications.

Where Palliative Care Is Offered

Palliative care targets patients with critically disabling or indicative chronic complications particularly in the end of living. Although children presently need attention regarding palliative care, the highly affected group includes the elderly, who are present within Aged Facility care centers (Abbey, 2008). This is especially in developed nations. Palliative care is significant in the management of terminally ill adults. Severe complications including cancer mostly render the sufferers disable thus posing pain and death as the end. Consequently, the families of such victims are traumatized since they can suffer psychologically. Aged Care Facilities provide suitable areas for offering end-of- life care to patients (Clark, 2002). In these facilities, complete attention is applicable to the residents who pay for these services. The care in these facilities provides the occupants with an admirable quality of livelihood. Most of these facilities minimize the possibility of patient transfer to hospice and hospitals. Because of this, the patients together with their kin stay within the environment and get assistance. They feel valued, secure, and comfortable within these facilities. In nations like Australia, there are stringent regulations and policies regarding the accreditation of such facilities (McNamara, 2004). Such policies ensure that there is proper management, safety, and patient dignity. External palliative assistance applies when there are conditions surpassing the existing internal competency.

In Australia, there exist guidelines for Palliative Approach in these facilities (McNamara, 2004). These offer assistance and direction for the dispensation of a palliative approach within these facilities across Australia. Moreover, the operating facilities follow these regulations and varied state workshops create awareness. In these facilities, the elderly get admission based on their health conditions. Those suffering from terminal illnesses such as cancer and dementia receive preference. There are trained professionals deployed within these facilities responsible for dispensation of palliative services to these patients. Occupants of these facilities are older and frail. They also have complex co-morbid complications and workers herein face problems in satisfying the complex care requirements of this varied group of persons. Aged care centers increasingly gain global popularity, with developed states leading with statistics. For example, there exist approximately 3,000 of such facilities within Australia alone (Cancer council, 2009). There are procedures, which contain quality scientific evidence present relating to the facets within palliative approach. These include prompt recognition and treatment of mental, physical, and other needs. The facilities form environments where occupants and families stay jointly without disturbing other people.

Persons Involved

Palliative care entails a multi-dimensional intervention procedure that covers the entire realms of life of the patient undergoing care. As a result, there are various personalities involved during the process. Each personality plays a distinct role, which culminates with other interventions that improve the patients lives. The residence of the patients within facilities provides an opportunity for full attention. With the elderly patients, there are more interventions (Rio-Valle, Caro & Juarez et al., 2009). Family members of the patients are also chief beneficiaries of these services. It is evident therefore that there is need for many professionals to offer the distinct services depending on the patients illness type and condition. In wider perspective, there is indulgence of many personalities such representatives from relevant sectors and beneficiaries. An efficient multi-disciplinary team must dispense palliative approach. Such teams ought to recognize and admit the significance of unity and teamwork in dispensation of such services (Abbey, 2008). Recognition of the centrality of positive team endeavors advances job fulfillment and increase the care quality to patients or family members.

A multidisciplinary strategy is vital since the wide array of anguish faced by occupants and their kin necessitates an expansive variety of skills. Such teams must focus its endeavors on solving the challenges that face the occupants. Persons involved include care assistants who act as personal aids to the patients and have special training. Others might also be from the patients family. General practitioners, (GP) who undergo training and have qualification on varied medical procedures exist (Bostro, Sandh & Lundberg, 2004).They render medical support involving specialized treatment and are available on call within the age care centers. Because patients may suffer from different ailments, there are different specialized GPs who offer skilled medical attention when appropriate. Registered nurses also form part of this team and assist the GP in their routine duties to the patients. Enrolled and specialized nurses may also be involved in palliative care within these centers (Soden, Ali, & Alloway et al., 2010). Specialist nurses may offer wound care and continence services. The aboriginal health staff, volunteers, and other coordinators form part of staff within the care centers. Volunteering is an essential component of palliative care. Pharmacists offer prescriptions and are responsible for drugs used within the care center.

The spiritual component of palliative care is critical and chaplains or pastoral care workers are responsible for spiritual nourishment and improvement. Additionally, recreational activities specialists provide vital recreation directives to patients, thus enhancing their physical components. Pain specialists and other healthcare specialists such as occupational therapists and physiotherapists form part of palliative care team. Social workers are vital members of the team. Moreover, nutritionists, music therapists, and skilled physicians such as surgeons exist. Neurologists and wound care persons also provide specialized services (Abbey, 2008). Among other important team members include the psychologists who provide psychological assistance to the patients. Lastly, the patients themselves as well as family members as residents of the care centers are recipients of the services and form essential component of any palliative team.

The People Who Receive Palliative Care

Most elderly persons around the globe face serious chronic complications while approaching the end of living. There exists a significant public health problem in trying to meet the demands of such persons. Better palliative care is necessary specifically for these elderly people. Because most elderly persons suffering from terminal illnesses are enrolled within care centers, these form the basic target especially in developed states (Agar, 2009). Despite high death cases in the elderly population, little guidelines regarding their particular needs towards death exist. As populations age, there is a gradual up scale of people into the elderly stage. Disease trends also transform and individuals die due to chronic devastating complications such as dementia and Alzheimers disease among others (Abbey, 2008). Because these diseases usually occur among the elderly, they face several health complications and disabilities. Therefore, there is need to provide proper and relevant palliative care to these groups.

According to World Health Organization (WHO), the percentage of persons of 65 years and above is gradually growing globally (Bostro, Sandh & Lundberg, 2004). The elderly suffer pointlessly, owing to prevalent underassessment and lack of therapy based on palliative care. Thus, elderly persons are the main beneficiaries of palliative care services. Within this category, keen attention is applicable to those suffering from dementia and Alzheimers illness. Additionally, those who suffer from Parkinsons disease are inclusive. The elderly who suffer from dementia experience serious irreversible cognitive decline. Other associated conditions include swallowing difficulties, weight reduction, anorexia, and dysphagia (Miyasaki, 2011). Advanced dementia refers to a progressive and degenerative illness. This is because it is life-limiting thuspalliative approach is necessary. The team offering the care should understand the nature of this illness and the patients family ought to comprehend the condition. In addition, they should have opportunity to understand the importance of the palliative assistance.

Alzheimers disease leads to dementia, which is more likely to cause death. The condition also predisposes persons to other infections that cause severe human suffering. Communication on the therapy course is important amongst participants including the patients. Parkinsons disease presents as a chronic and neurological illness that affects several people annually (Abbey, 2008). The elderly are most at risk and palliative care becomes necessary. Although significant progress is evident, treatment benefits in advanced stages reduce and symptoms get more complex to manage. This life threatening condition thus requires palliative care as recognized by WHO (Agar, 2009). Its model applied in care directs specialists in provision of care to families and individual patients. All these conditions are life threatening and affects the more vulnerable elderly population. It is therefore evident that the group needs a proper palliative care.

What Is Good About the Services Offered?

Provision of care to facilitate good death is a remarkable medical practice that also gives the backdrop that permit the bereaved to mourn appropriately. A comprehensive approach is applicable for service provision within these facilities. Symptoms control, sustained care, and minimizing caregiver strains are essential fundamentals of care used in managing patients approaching death. Provision of these services within the facilities enable the patients to regard positively their status and may consequently transform the disease course. Clinical management of various conditions reduces depression in patients (Bostro, Sandh & Lundberg, 2004). The integration of progressive care planning initiatives within various care centers helps to improve the patient conditions. Training of stakeholders such as care providers assist in advancing care. Pain management offered in these facilities is a vital component of excellent terminal care. There are complimentary interventions such as body massage and music therapy for patients. These services help to build the physical as well as the social aspects of these patients. The general practitioners are always present to the disposal of patients and services such as acupuncture help to reduce pain and increase patient comfort.

Notably, systemic apprenticeship for workers caring for the facility residents as well as application of acknowledged care methodologies are important. Availability of specialist services and interventions within these facilities enable proper management of diverse conditions. The holistic approach to service provision is a great achievement in enhancing patient progress and comfort in all realms of life. Furthermore, the execution of advanced care planning provides room for management of severe terminal illnesses such as advanced dementia (Hall, Petkova & Tsouros et al., 2011). The elderly are more vulnerable and can easily succumb to distressing and agonizing conditions. Palliative care to these groups therefore provides a timely intervention and support for the almost dying elderly population. Proper management of Alzheimers disease may reduce the changes for progression into advanced dementia. Moreover, the availability of drugs and other prescriptions coupled with medical attention within the facilities offers opportunity for prompt diagnosis and therapy. Assessment, management, and family assistance play constructive roles in completely transforming the patients view and attitudes towards their conditions. The family members support system provides a holistic approach to problem handling. Provision of cognitive behavioral therapy, (CBT) by psychiatrists is vital for improvement of the mental capacity of the elderly particularly suffering from conditions such as dementia (Hicks & Rees, 2008).

There is minimization of stress and other effects likely to be transmitted form victims to other family members. This consequently minimizes the percentage of patients to be attended. Symptom assessment coupled with efficient pain management includes some of the vital services in these centers. The patient dies in relief and stigma reduces significantly at the end of-life stage (Agar, 2009). Other complications including fatigue and nutrition problems such as anorexia exist. Provision of psychological support minimizes likelihood of depression and anxiety by individual patients as well as their families. Family and social assistance initiates positive effects. Additionally, spiritual support nourishes the dying individuals and their kin and consequently potentiates death as a normal occurrence in a lifetime. Support from volunteering initiatives and terminal care all improve the quality of living before death. Lastly, bereavement support is vital in consolation of the family and offering psychological assistance. It is evident that with growing complications in the enlisted diseases such as dementia and Parkinsons illness, critical clinical as well as other approaches to palliative care matter.

How to Improve the Services Offered

There still needs to be a lot done in order to improve on the services offered within these age care centers. Foremost, adherence or compliance to existing guidelines on palliative care present within nations like Australia is necessary. These guidelines exist to provide the fundamental premises on which palliative approach should follow. Due to the existent of several age care centers in certain states such as Australia, there needs to be a more harmonized system that regulates their operations and protects the interests of the patients (Edith Cowan University, 2006). Without such systems, there can easily be abuse of patient rights and maltreatment particularly with euthanasia issues. There should be additional research about potentially valuable interventions and other complications including newly emergent illnesses such as Parkinsons disease other than cancers (Hicks & Rees, 2008). Due to the transformative nature of current disease trends, further empirical and, medical investigations are necessary to develop beneficial strategies to palliative management. Consequently, results should initiate the adjustment of existing palliative approach guidelines and enforce change in the medical management procedures applicable in normal situations. A complete overhaul of palliative care systems is necessary with growing contemporary concerns in clinical arena.

Proper empirical diagnosis is necessary to establish whether a patient is dying and provide him adequate care. There should be an evident-based system of enrollment of patients and families in any age care center. This will support the medical ethics relevant for specific life-threatening conditions (Soden, Ali, & Alloway et al., 2010). However, effective diagnosis requires adequate familiarity and qualification within different medical fields. Qualified professionals and practitioners are therefore applicable for such undertakings. It is important to practice participatory decision making as members involved in dispensation of palliative care. However, critical decisions regarding the condition of the patients, whether they are to die or not solely rely on qualified medical personnel. Effective communication as well as feedback sharing amongst the care team and families of patients is necessary to improve their relationships and prohibit false hopes (Mitchell, 2008). Some indicative signs of a dying patient may include change in complexity, gauntness, minimized oral intake, temperature fluctuations, disoriented concentration, and others. The caregivers must be aware of these signs to be competent of recognizing terminally ill patients.

Adoption of holistic approach by those offering palliative care is vital in examination and management of pain. Additionally, all components within palliative care are equally useful and disregard of any such as psychological component may cause dangerous implications on patients and families. There also exist notable training demands regarding pain assessment and critical clinical decision procedure (Qaseem, Snow & Shekelle et al., 2008). Teamwork amongst the care providers is vital in order to initiate these transformations and focus on forward movement. Strategic management of existing care centers for the elderly is necessary also to offer excellent services and meet the client demands. Patient satisfaction with the offered services should be the major goal for these care homes. Voluntary service should also accompany as an important aspect for palliative care since some patients maybe unable to meet the high fee demands procedures (Hall, Petkova & Tsouros et al., 2011). Standard professional ethics is necessary in palliative care because the patients face death and controversies from legal bodies or families might arise. Due to this, adequate information and discussion is necessary between parties before any procedure is undertaken.

There is a demand for improvement on virtue ethics and professional conduct. Consequently, there is need for care providers such as nurses to be honest during service (Erichsen, Danielsson & Friedrichsen, 2010). Individual assumptions should be outplayed to enhance open and candid communication according to clients independence and recognition of preferences (Powis, Etchells & Martin et al., 2004). Feelings and instinct should not lead to improbability and ethical variance. Principally, human beings require special attention even in death. Therefore, care is necessary while dealing with terminally ill persons. Initially, one cannot declare a fellow before prior intensive medical diagnosis. As indicated in most sources, simple complications are likely to develop to severe forms with incorrect diagnosis and admission of patients for palliative care. In conclusion, palliative care is a crucial; furthermore, distinct medical field that is globally gaining recognition with the advancing age of most populations equally assumes the same stature. High attention to ethical procedures is necessary for such a practice. Furthermore, a multidisciplinary strategy offers complete care when various guidelines existing within different nations are followed. Other than developed states, emergent nations presently face the need to consider palliative care as a critical public health concern.

References

Abbey, J. (2008). Develop, trial and evaluate a model of multi-disciplinary palliative care for residents with endstage dementia. Web.

Agar, M. (2009). Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches. Palliative Medicine, 23(3), 257-265.

Bostro, B., Sandh, M., Lundberg, D. & Fridlund, B. (2004). Cancer-related pain in palliative care: patients perceptions of pain management. Journal of Advanced Nursing, 45(4)410-9.

Cancer council. (2009). Understanding Complementary Therapies: A guide for people with cancer, their families and friends. New South Wales: Cancer Council New South Wales.

Clark, D. (2002). Between hope and acceptance: The medicalisation of dying. British Medical Journal, 324(1), 905.

Edith Cowan University. (2006). Guidelines for a Palliative Approach in Residential Aged Care. Web.

Erichsen, E., Danielsson, E. &Friedrichsen, M. (2010). A phenomenological study of nurses understanding of honesty in palliative care. Nursing Ethics, 17(1)39-50.

Hall,S., Petkova, H., Tsouros, A., Costantini, M. & Higginson, I. (2011). Palliative care for older people: better practices. Web.

Hicks, F. & Rees, E. (2008). A pain-free death. British Medical Bulletin, 88(1), 23-41. Web.

McNamara, B. (2004).Good enough death: autonomy and choice in Australian palliative care. Web.

Mitchell, G. (2008). Palliative care: a patient-centered approach. Oxon, OX: Radcliffe Publishing.

Miyasaki, J. (2011). Palliative Care in Parkinsons. Web.

Powis, J., Etchells, E., Martin, D., MacRae, S. & Singer, P. (2004). Can a good death be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients. BMC Palliative Care, 3(2), 1-8.

Qaseem, A., Snow, V., Shekelle, P., Casey, D., Cross, T. & Owens, D. (2008). Evidence- Based Interventions to Improve the Palliative Care of Pain,Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline. American College of Physician, 148(1), 141-146.

Rio-Valle, J., Caro, M., Juarez, R., Pena, D., Vinuesa, A., Pappous, A.& Quintanna, F. (2009). Bad News for the Patient and the Family? The worst part of being a health care professional. Journal of Palliative Care, 25(3), 191.

Soden, K., Ali, S., Alloway, L., Barclay, D., Perkins, P., & Barker, S. (2010). How do nurses access and manage breakthrough pain in specialist palliative care inpatient units? A multicentre study. Palliative Medicine 24(3), 294-8.

Twycross, R. (2003). Introducing palliative care. Oxon, OX: Radcliffe Publishing.

What is your understanding of Palliative Care?

The definition of Palliative care is constantly changing. In the early 1970’s the term palliative care was introduced by Balfour Mount Medicine (AAHPM) defines palliative care as “ to prevent and relieve suffering and to support the best possible quality of life for patients facing life-threatening or debilitating illness and their families regardless of the stage of the disease or the need for other therapies” (AAHPM, 2009). Both definitions complement each other as the number one goal is to relieve one of their suffering and that of their families. Any patients, whatever age they may be should be offered specialised palliative care if they are suffering from a terminal illness or incurable disease. There are many other terms that are used to describe palliative care such as terminal care, hospice and end of life care. At times these are used throughout literature and within work places (Kai Yeung and Kai Chui, 2016; Well et al., 2015). Nevertheless, these terms are not the same as palliative care and are usually mentioned towards the end of palliative care (Baslo, 2015).

Anciently, palliative care was usually linked with cancer care (Shearer et al., 2014). Now, with the population aging around the world (Bailey et al., 2011c) and more treatments being introduced for long term conditions, life expectancies of people are much longer than before (McIlfatrick and Murphy, 2013). Palliative care is now covering all branches of care such as AIDS, dementia and chronic renal function (Basol, 2015). By 2026, the population of those over sixty five and those over eighty years of age is expected to increase by 2026 and double in 2046 (Central Statistics Office, 2013).

The World Health Organisation (WHO) predict that more than twenty million people around the world will require palliative care towards the end of their lives (WHO, 2016). The Health Service Executive (HSE) developed a national framework plan that entilites every patient and their families to some aspect of palliative care despite the care facility they are in or health issues they have (HSE, 2009). This was to encourage services to work together and combine with other programmes like the Emergency Medicine Programme which also incorporates a section on the needs of palliative care patient in the emergency department (HSE, 2012).

While there has been substantial research carried out, together with a Irish survey (McCarthy et al., 2010), it implies that older Irish adults would rather receive palliative care in their own homes but it is shown that many of the deaths in Ireland occur in the acute setting (McKeown, 2010). Five years ago, the Economist Intelligence Unit graded many countries around the world on their quality of palliative care. The United Kingdom ranked number one with Ireland coming forth overall. They looked at areas such as health care conditions, how affordable health care was in the country, the uptake of health care in the country as well as the standard of health care. This brought to our attention how challenging providing palliative care to all of the citizens was and how there will be increasing demand for palliative care in the future as found previous people are living longer with many chronic diseases (Economist Intelligence Unit, 2015, p.22).

The emergency department is a vital department within any acute hospital. They are often seen as ‘fast paced, life-saving, heroic environments’ (Norton et al., 2011, p. 240). Emergency departments create access to many specialities of health care twenty four hours a day. Many palliative patients present to the emergency department seeking relief from a wide range of symptoms such as nausea, constipation, vomiting, diarrhoea or fever (Smith et al., 2009). The emergency department regularly provide care for palliative patients. There has been numerus studies carried out around the world regarding the provision of palliative care in emergency departments. In 2011, in Western Australia, a study was carried out and it was found that intensive and progressively more care was being carried out within their emergency departments on palliative care patients within their last three to four months of their life (Rosenwax et al., 2011). It can be said that there are many barriers to implementing palliative care protocols within the emergency department. These include time restraints, liaising with community teams with aim of discharge, attitudes of care providers and expertise (Ouchi et al., 2019). In 2016, a systematic review was carried out by da Silva Soares et al. They found that having a palliative care screening tool within the emergency department did not have any effect on patients medical outcomes. In a more recent study carried out by Wilson et al., (2020), they found that although palliative care strategies introduced in the emergency don’t prolong patients life or survival time, it does improve their quality of life at that present time. However, they do agree that further research needs to be carried out to clarify the impact palliative care interventions in the emergency department have on palliative patients. As per the World Health Organisation (WHO, 2015), Quality of life is defined as “the individuals perception of his or her position in life in the context of culture and value system”.

The need for suitable education and training of health practioners in the emergency department on palliative care is vital (Russ et al., 2015; Granero-Molina et al., 2016; Batchelor, 2015; Peters et al., 2013). In 2011 in America it was found that there were only twenty emergency practioners that had a qualification in palliative medicine (Quest et al., 2011). This was sub-sequently found in many other countries especially with junior doctors and general practioners (Economist Intelligence Unit, 2015). Here, in the Republic of Ireland and Northern Ireland a report was also carried out to establish the need for palliative care education within the country. It included all acute and community based health centres. It discovered that there is a great need for further education to be carried out and it was a priority for health providers (AIIHPC, 2014). They enable this by encouraging staff to take study leave to be at seminars, carry out post graduates and any funding that may be required to further their education. In 2008, the National Council on Ageing and Older People along with the Irish Hospice Foundation issued a report which zoned in on the educational needs of health care staff as well as ethical and legal matters, available facilities and the perspectives of older people in Ireland on dying in the acute or long term setting. In the responding settings, it highlighted that less than one third of staff nurses had a palliative care qualification and in only one third of settings had any of the healthcare staff have any courses done in palliative care. Less than fifteen percent expressed that their doctors had no medical training in palliative care or end of life care (O’Shea et al., 2008).

In 2009, the Irish Hospice Foundation had a national forum which they released data from, showing the key aspects Irish people were most worried about when it came to end of life care or palliative care (Carroll, 2010). The number one issue the public were most worried about was moving from home or a long stay centre to the Emergency Department. Factors such as understaffing and lack of education and knowledge in residential centres and families feeling guilty, panicked or felt over their heads when acute deterioration began all contributed to this issue. When these events happened, patients end up being transferred to their local emergency departments. When patients need to visit the emergency department their needs are not being met at home such as pain management (Barbera et al., 2010; Basol, 2015). Emergency departments around the world are vital access points for people requiring acute treatment (Weil et al., 2015). In Ireland, the emergency department is deemed the entry point for one to gain access to palliative care and be placed in the appriopriate setting. Although access to this seems to be emergency led rather than electively led (McKeown et al., 2015).

Although twenty five years old, a study carried out by The Support Principal Investigators (1995), discovered that palliative care patients presenting to the emergency departments failed to receive the care they expected and even more so, many patients had their first experiences of end of life or palliative care within the emergency department. Health practitioners within the emergency department have a special chance to provide person centred palliative care at the earliest point in a patients disease outlook by encouraging a good quality of life, pain management plans and reducing the need for unwarranted treatment (Lamba, 2009). Overcrowding within our emergency departments impede greatly on patients requiring palliative treatment. Many of times they are not given the privacy they may require or the support that they rightfully deserve. Lack of time and seems to be the most identified reason for this (Sorlie et al., 2004). Many patients pass through the emergency department without any mention of a palliative care review (Kistler et al., 2015).

The Emergency department can be described as a chaotic environment with nurses and doctors having large caseloads of patients to care for. Emergency departments are in general not the ideal area in which dying should happen (Bailey et al., 2011a) but it is commonly becoming the location of many deaths and end of life care. There are many barriers with in the emergency department when giving quality end of life care. Examples such as noise levels (monitors, call bells, confused patients and overcrowded departments), high patient case-loads and time constraints (Basol, 2015). There are two deaths that commonly happen within emergency departments. Number one being the ‘spectacular’ – the unexpected traumatic death of a person with courageous effort to save a life. Number two being the ‘subtacular’ being it does not draw attention of many staff, has a lower priority and does not require courageous effort (Bailey et al., 2011b). The number of deaths within the emergency department are non-traumatic. They are usually prioritised lower than the spectacular and especially when both are happening at the same time. When this happens families of the dying patient feel left out and have a feeling of abandonment for both themselves and the family (Bailey et al., 2011b).

A major worry for patients and their families within the emergency department is the long wait times (Wilper et al., 2008). This delays pain management and symptom control for patients which raises families and patients anxiety levels. Glajchen (2004), discovered that many patients were brought to the emergency department by their family members as family members have gotten scared at home as the patients symptoms have become unmanageable (Hjermstad et al., 2013). This discovery proves the high demands patients families or care-givers have at home with their family members health deteriorating.

Worldwide evidence portrays that a high number of patients over the age of sixty five used the emergency department at least once in their last six months before death (Basol, 2015; Barbera et al., 2010). In a study between 1992-2006 in the United States on older people, it was established that over seventy present of now deceased people presented to the emergency department in their last six months of life and many had re-presentations in last four weeks of life (Smith et al., 2012). There were many purposes of these presentations such as pain management, family burden and not feeling safe at home (Hjermstad et al., 2013).

Patients main concerns when palliative care is introduced is, remaining in control, sorting out any financial affairs and tightening family bonds (Robin Cohen et al., 1997). Many of times health practitioners fail to discuss patients goals, in case they are not welcomed, however, it was found that patients welcome these discussions greatly and usually cause minimal distress (Robinson, 1983). Early palliative intervention within the emergency department can improve quality of life, prevent long stays in hospital and it may prolong life (Emanuel, Alpert and Emanuel, 2001). If staff are more aware of patients care goals this may reduce the amount of palliative patients needing admission to the hospital from the emergency department and may encourage hospice care or home care packages to be put in place. In a study carried out by (Grudzen et al., 2016) which trialled emergency initiated palliative care in advanced cancer patients. They found that early referral to the palliative care team greatly enhances quality of life and does not have any negative effect on mortality.

Within the last five years numerous amounts of studies has been carried out to decide whether introducing palliative care interventions within the emergency department or beneficial or not. This confirms that ongoing research should be carried out regularly. The more widespread research that is carried out may encourage a greater importance of palliative care being introduced in the emergency department as people are living longer and documentation is improving as time goes on. It is easy to see that our population is aging and people are living longer (Bailey et al., 2011c). Emergency department attendances are increasing and patients with complex and significant diseases will continue to increase and present to our emergency departments (Xu, Nelson and Berk, 2009). The aim of palliative care is to assess symptoms and advise treatments, help with any decisions that may need to be made and creating patient goals in relation to their care, giving support to families and patients care – givers and introducing community based interventions to ensure their environment is suitable at home (Meier and Beresford, 2006).

As the population ages and emergency department (ED) visits continue to increase, 2,3 the number of older adults with serious and complex illness who present to the ED will also continue to rise.

Palliative care improves the quality of life and diminishes symptoms for individuals diagnosed with a serious illness. Also, it assists patients to understand all of their choices for medical treatment. It is useful at any stage of the illness, but is most effective if provided from the point of diagnosis. It can be provided to the patient along with curative treatment; therefore, it is not a requirement of the patient to stop any treatment that might cure the serious illness. Over time, if the treatment for the illness is no longer helping the individual, palliative care can continue to focus on increasing comfort or the patient can transition to hospice care (National Institute on Aging, 2017). Hospice care differs from palliative care as it is chosen at end of life, typically for symptom relief when the patient’s doctor believes they have six months or less to live. Hospice care is designed for the time when it may not be possible to cure a serious illness. All treatments to cure the individual’s illness are stopped and hospice care provides comfort care and support for the family. A team of nurses, doctors, social workers, spiritual advisors and trained volunteers are brought together to work with the patient and the family to provide the medical, emotional and spiritual support the patient needs. If hospice care is being provided at home to the patient, the hospice team coaches the family how to care for their loved one. Lastly, respite care is provided if the family needs a break from caring for the patient (National Institute on Aging, 2017).

Many Canadians in their last year of life could benefit from palliative care, but only 15% are receiving it. It is revealed by the Canadian Institute of Health Information that those who receive palliative care obtain it too late and too many patients are subject to multiple transitions of care as they are repeatedly moved around from their home, hospital and nursing home in their final days of life. Many individuals wish to die at home, but if they are not provided access to palliative care at home or are constantly being shuffled around, it is rare for their request to occur. Only one in four terminally ill patients who are hospitalized receive palliative care and half of them die while waiting to be discharged to a more suitable setting. The majority of Canadians die in hospitals where a peaceful and dignified death is rarely possible. The primary problem of palliative care in Canada is the lack of timely access and the distress caused by the lack of coordination between different parts of the health care system. Basic planning is the key to efficient palliative care. For example, cancer, cardiovascular disease, chronic obstructive pulmonary disease and diabetes account for majority of deaths and they all have predictable courses in the terminal phase; therefore, providing palliative care should be a priority. Moreover, Picard proposed a solution to easily resolve all the problems. Paramedics can provide palliative care which eliminates hospital transfers and doctors or nurses can be sent to the patients’ home or nursing home to have more hospital beds available. Overall, a change is required in the Canadian health care system of how palliative care is provided to support many patients at home, in nursing homes or in the hospital (Picard, 2018).

It is rare for Canadians to receive palliative care at home in their last year of life. Of the adults who died in 2016-2017 for Ontario and Alberta, 66% received some type of home care service in their last year of life and fewer than 1 in 6 people (15%) received palliative home care. It would be beneficial for the patients and the health care system if palliative care could be integrated earlier. Most individuals who had palliative care in the year of 2016, only received it in their last month of life. Access to palliative care in long term care homes in limited as, 24% of the residents who died in 2016-2017 were identified as having less than 6 months to live and of those residents, only 6% received palliative care in their last year of life. It is reported that patients who received palliative care earlier on were less likely to visit the emergency department as palliative care in long term care homes helps to prevent hospital transfers. Of the residents that received palliative care in long term care and died in 2016-2017, 97% of them died in their residence and 2% died in hospital. On the other hand, 77% of the residents who did not receive palliative care died in the long term care home and 18% died in hospital. Also, if patients could receive palliative care earlier on, it would decrease the amount of patients who are admitted to intensive care units for aggressive treatments. In 2016-2017, 25% of people who died in an acute care hospital received palliative care and 44% were initially admitted for an acute health issue, but once the problem worsened they were then designated palliative care. Majority of the time when patients received primarily palliative care in the hospital, it was unplanned or the patient was admitted through the emergency department. Following this, patients had to wait about 9 days to be discharged to a more appropriate setting for palliative care. Overall, palliative care is a current issue in Canada in terms of access and appropriate setting (CIHI, 2018).

Rawls theory of justice is constructed around the idea that all individuals are free and equal and that society should be fair. He views it as reconciling the tensions between the ideas of freedom and equality. His theory expresses the central idea that cooperation should be fair to all citizens considered as free and as equals. Rawls believes that citizens do not deserve to be less equal or at a disadvantage to another individual. All social goods are allocated equally to all citizens, unless an unequal distribution would be an advantage to everyone. Furthermore, any inequalities must benefit all individuals, including those who have the least. Rawls theory is not designed to address health issues as he assumed a healthy population that doesn’t experience negative effects from disease. Since Rawls classified the population as healthy, he was able to conclude fairness, equality and the same opportunities for all citizens (Wenar, 2017).

Norman Daniels considers health care special because it sustains normal function and allows opportunities for citizens. If people are kept close to normal functioning, it gives them the opportunity to participate in their society. Furthermore, the association between health care and opportunity proposes that the appropriate rule of distributive equity for directing the structure of a health care system is a standard protecting equality of opportunity. A fair process is required to set up the justification for resource distribution choices. This should be avoided by not biasing our designation for one phase of life and alternatively we should consider the age-relative opportunity range. Sparing assets from one phase of life for use at another doesn’t deliver inequalities across people in the manner that differential treatment by race or sexual orientation does. Equity between age groups in structuring a health care system is properly displayed by the possibility of inequality over a life expectancy. Rawls justice as fairness opportunity promotes “fair equality of opportunity”, as discrimination is not allowed and positive social measures are required to correct for the negative consequences. Lastly, our levels of well being should be evaluated by freely open measures which implies a list of essential primary social goods that incorporates rights and freedoms. Overall, justice as fairness greatly affects palliative care in Canada through protecting opportunity (Daniels, 2001).

Aim

To provide the relief from pain and care for the patients who are at the last stage of cancer, by creating spaces related to activities which a soothing effect on the inhabitants which eventually acts generate as a stress reliever.

Objectives

• To analyse the factors that affect human and human psychology health and their influences which improves the quality of life.
• To establish the need for an architectural design in healthcare environment.
• To study the model centres (case studies).
• To study the ideas of design for the current medical environment.
• To choose appropriate site accessible and feasible in all respect.
• To plan and design a centre where holistic care is given to the patient and their caregiver, as well as making it climate and surrounding responsive.

Scope

Patient-oriented design strategy.

To provide view of the outdoor and cultural elements.

Limitations

The relationship of architecture and human perception is limited to cancer patients who spend a majority of their time in the given frame of an environment.

The centre is limited to patients who suffer from Cancer.

Abstract

The basis of this project thesis is to introduce a new building type that serves terminally ill patients, both adults as well as children, & their family members by creating a building that is designed & prepared to meet their required needs. This thesis aims to interpret ‘Hospice & Palliative Care Centre’ & defines related terminologies in an attempt to examine this type of building in Navi Mumbai particularly in Kharghar. Nowadays several chronic diseases have appeared & the number of dying terminally ill patients is increasing, whereas hospitals are occupied with patients who are not in need for cure, only in need for treatment & conditions management. Hospice & Palliative Care Centre is becoming a global society need to fill some of the gaps that hospitals are no longer able to.

This thesis includes the introduction, definition of related terminologies, project’s background study, need of the project, project’s aim, objectives, scope, and limitations.

It also includes several case studies of Hospice & Palliative Care Canter’s around the world in order to gain a profound understanding of the project. This helps in understanding different planning’s and design strategies used in various Hospices by comparing them.

It includes formation of a design brief, design program of project and its detailed area statement.

It presents criteria of site selection and justification to evaluate a site in Navi Mumbai, to locate the project which will be analysed based upon location, landmarks, climatic conditions & existing challenges.

Hospice

Hospice is a home where the terminally ill patient is offered pain management and relief so as to make them feel comfortable.

Hospice is a concept, a program of care. Whatever its form, the final goal remains the same, to respect the dying and allow them to end their lives in harmony with themselves. Hospice emphasizes palliative rather than curative treatment, quality, rather than quantity of life.

The term Hospice is primarily associated with a particular building or institution that specializes in holistic care and adopts the principles of palliative care. Such institutions provide care mostly in an end of life settings but they may also be available for patients with other palliative care needs. The care also involves assistance for patient’s families to help them cope with what is happening and provide care and support to the patient.

Professional medical care is given, and sophisticated symptom relief is provided. The patient and family are both included in the care plan and emotional, spiritual and practical support is given based on the patient’s wishes and family’s needs.

In a hospice design, there are three type of users –

The patient, the family, and the caregivers.

For the patient, hospice becomes a second home. They enter the facility knowing that they might never leave. For the family, it provides a safe place to spend more quality time with their loved ones. In addition, for the caregivers, it is a place of work, but also where they become like family to their patients; a place where they need to be the strongest ones to help others with their physical and emotional needs. Hospice tries to heal the wounds of the dying not by curing or fixing, but rather a return to balance and re-establishing harmony between body, mind, and spirit.

Unlike an adult hospice where the care provided is comparatively short and at the end of an adult life, a children’s hospice works alongside the family through the months, maybe years of care and beyond until death. At a children’s hospice the whole family can stay if they wish, at repeated intervals.

Hospice is a model for delivery of palliative care for patients at the end of life when curative or life-prolonging therapy is no longer beneficial.

Background study

Dealing with the death of beloved one is challenging experience for surviving family members. Patient with advance cancer have many physical and psychological needs which may long before patient’s death. At last stage of cancer patient is ignored by family and society at times, but the patient needs physical, emotional, spiritual, social needs, distress painless life and their own space.

Origin of a hospice and palliative care centre

By the 1950s, social trends were changing and most people died in hospitals rather than in their own homes. This change reflected the growing number of treatments available in hospitals. The medical profession increasingly saw death as failure.

Since the early 1980s, the need for palliative care for cancer patients has been progressively acknowledged worldwide. More recently, there is increased awareness of the need for palliative care for other chronic diseases or conditions such as HIV/AIDS, congestive heart failure, cerebrovascular disease, neurodegenerative disorders, chronic respiratory diseases, drug-resistant tuberculosis, and diseases of older people. However, there remains a huge unmet need for palliative care for these chronic life-limiting health problems in most parts of the world.

Cancer was the most feared diagnosis. Physical pain afflicted at least three quarters of cancer sufferers and appropriate painkillers were rarely used. Morphine was considered addictive and too dangerous.

‘Hospice’ comes from a Latin word ‘hospitium’, meaning hospitality, and was used in the middle Ages in Europe and Mediterranean regions to describe a place of rest for travellers and pilgrims. Established and run by religious orders, these places offered special hospitality and care to travellers who were far from home and to people who were ill or dying.

The hospice disappeared for a while, but re-emerged in the 19th century in the UK and France particularly, again run by religious orders, and again caring for people who were terminally ill, but also providing accommodation for the incurable and destitute. At that time there was a growing awareness that 20th century medical advances, while offering a cure for many illnesses, also resulted in the health system ignoring those people who could not be cured.

Cicely Saunders, originally a nurse, then a social worker (almoner), finally studied medicine to meet this challenge, the neglect of the suffering of the terminally ill. Her work in building St Christopher’s Hospice and her approach to pain and symptom management, recognizing the multi-dimensional nature of suffering and the need for emotional, psychological and spiritual support for both the terminally ill patient and their family was the foundation for modern hospice and palliative care practice.

The term ‘palliative care’ was first used in 1975 by Canadian surgeon Balfour Mount, an early Cicely Saunders pupil.

Mount developed a comprehensive hospital-based service at the Royal Victoria Hospital, Montreal that included an in-patient ward, consultation service, home care programme, and bereavement support service under the name Palliative Care service by which he meant non-curative therapy aimed at improving the quality of life.

Relation between hospice and palliative care centre

Hospice care and palliative care are very similar when it comes to the most important issue for dying people. Hospice provides “palliative care,” and that palliative care is both a method of administering “comfort” care and increasingly, an administered system of palliative care offered most prevalently by hospitals. Hospice and palliative care protocols call for patients to receive a combined approach where medications, day-to-day care, equipment, bereavement counselling, and symptom treatment are administered through a single program. Where palliative care programs and hospice care programs differ greatly is in the care, location, timing, and eligibility for services.

Difference between hospice and palliative care for adults and children

Paediatric hospice palliative care is based on the same principles as adult hospice palliative care but also recognizes the unique needs of families faced with a child’s illness and death. Children and adolescents are in a process of physical, emotional, cognitive and spiritual development. Depending on their developmental stage, they have different skills and different emotional, physical and development issues/needs.

Children and adolescents communicate differently, and their understanding of illness, death and dying depends on their stage of development. Health care professionals understand that a child’s concepts of illness and dying continue to evolve over time, and develop in association with life and illness experience. Religious/cultural beliefs, patterns of coping, disease experience, previous experience with loss/death, sadness and other emotions associated with grief, all influence a child’s understanding of death.

Children are members of many communities, including families, neighbourhoods and schools and their continuing role in these communities should be incorporated into their dying journey.

Children respond differently to therapies and drugs. They experience unique symptoms, such as fatigue, nausea, vomiting, and shortness of breath, depression and anxiety, which are not well understood. They experience and express pain differently than adults, and require individualized treatment. Children are not as able to advocate for themselves, and often rely on family members to make decisions for them.

Many life-threatening conditions that affect children are rare and only affect children. Many of the illnesses are familiar and may affect more than one child in the family. The diseases are often unpredictable in terms of prognosis, and children may require years of caregiving.

Parents bear a heavy responsibility for the care of their child, which may include making decisions in the best interest of the child at a time when they are highly stressed and grieving the loss of their child’s health as well as dealing with other losses such as financial stability and the loss of time to spend with other children. Families of children who have life threatening conditions tend to be younger and have fewer resources. Their quality of life is significantly improved when the ill child’s quality of life is enhanced.

The grief associated with a child’s death has devastating, long-term implications for the entire family. Siblings have unique needs during and after a child’s death.

Project justification

Palliative care is 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.

Palliative care seeks to enhance quality of life. It also positively influences the course of an illness and when applied early during the course of an illness may prolong life. It is active total care which works best in conjunction with other therapies such as chemotherapy or radiation therapy which often have distressing side-effects. Empathetic communication and psychosocial counselling are an integral part of it.

The aging of the population, success of high technology medicine at prolonging the lives of those who remain seriously ill, and the increasingly fragmented medical system make it difficult for clinicians to provide the full range of services required by patients with serious illness and their families .A multicentre study of over 9000 seriously ill patients found that pain, anxiety, and depression were common and distressing symptoms among seriously ill patients.

In summary, palliative care:

• Provides relief from pain and other distressing symptoms;
• Affirms life and regards dying as a normal process;
• Neither to hastens nor postpones death;
• Integrates the psychological and spiritual aspects of patient care;
• Offers a support system to help patients live as actively as possible until death;
• Offers a support system to help the family cope during the patients’ illness and in their own bereavement;
• Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated

Palliative care is considered as 4th level of treatment by WHO

• Prevention
• Early Detection
• Treatment
• Palliative Care
• Prevention
• Early Detection
• Treatment

Palliative Care

It was first introduced as end-of-life care. But now WHO suggests including palliative care in the early stages of treatment to meet the early psychological, social and spiritual needs of cancer patients.

Currently, Hospice and Palliative Care Centres in India is facing a lot of problems:

• Lack of awareness in public which creates delays in bringing patients to palliative care units.
• Disease acceptance problem for patient and family.
• Imitate on western models of care.
• Transportation difficulties.
• The communication gap between the Hospitals, NGOs and Volunteers.

In India, it is estimated that there are 2 to 2.5 million cancer patients with about 0.7 million new cases coming every year and nearly half die each year. More than 60% of these affected patients are in the prime of their life between the ages of 35 and 65 years. The World Health Organisation has said that there could be 50 million new cancer patients by 2020.

Figure 1.3 STYLEREF 1 s Error! No text of specified style in document. SEQ Figure * alphabetic s 1 a Rate of Cancer

Figure 1.3 STYLEREF 1 s Error! No text of specified style in document. SEQ Figure * alphabetic s 1 b Rate of Cancer Patients(Source:- Google Image)

Figure 1.3 STYLEREF 1 s Error! No text of specified style in document. SEQ Figure * alphabetic s 1 c Incident Rate of Cancer Patients in India

Figure 1.3 STYLEREF 1 s Error! No text of specified style in document. SEQ Figure * alphabetic s 1 d Mortality Rate of Cancer Patients in IndiaCancer Statistics in India 2018

Estimated number of people living with the disease: around 2.25 million

Every year, new cancer patients registered: Over 11,57,294 lakhs

Cancer-related deaths: 7,84,821

Risk of developing cancer before the age of 75 years

Male: 9.81%

Female: 9.42%

One woman dies of cervical cancer every 8 minutes in India.

For every 2 women newly diagnosed with breast cancer, one woman dies of it in India.

Mortality due to tobacco use in India is estimated at upwards of 3500 persons every day.

Tobacco (smoked and smokeless) use accounted for 3,17,928 deaths (approx.) in men and women in 2018.

Total deaths due to cancer in 2018

Total: 7,84,821

Men: 4,13,519Women: 3,71,302

Risk of dying from cancer before the age of 75 years is 7.34% in males and 6.28% in females.

Cancers of oral cavity and lungs account for over 25% of cancer deaths in males and cancer of breast and oral cavity account for 25% cancers in females

Advantages and Disadvantages of Hospice and Palliative Care Centre (Source Author)

Discussion Questions 1

The benefits of palliative care for a patient with a terminally ill disease are numerous. First, palliative care follows a patient-centered holistic approach that focuses on the mind, body, and spirit. Palliative treatment includes the psychosocial, spiritual, pain management and management of symptoms that are specific to the patient. The palliative care team is made up of physicians, nurses, social workers, and other staff that help formulate a treatment plan to ease the transition from disease fighting to providing comfort and quality of life. In the case of Mr. J., chemotherapy was not going to change the disease process, therefore a referral to palliative care would help alleviate the patient’s needs associated with end-of-life care. Palliative care would help facilitate communication between the medical team, the patient, and the patient’s family’s current needs and goals. It would allow the patient to have more control over decisions of care while receiving extra support and understanding to continue living life. Any symptoms and stress associated with the illness would be better managed and the family can receive support and coping strategies to better deal with the management of care. Lastly, the burdens associated with hospital costs and treatment would decrease, both for the family and the hospital facility.

The primary idea behind palliative care is asking the patient and their family questions specific to their needs and goals. Since palliative care does not target the prognosis or the disease itself, it’s important to work together as a team to alleviate any burdens that can prolong or cause additional stress. For instance, if the daughter is busy keeping the patient company, it will be difficult to tend to their family and cook meals.

The palliative team could help find strategies such as a meal preparation and delivery programs that may assist in providing services to the patient and his daughter. Another idea would be to assess the patient’s home environment and determine if there are any special arrangements that can be made to facilitate the patient’s daily living routines.

Another benefit of palliative care is the management of symptoms associated with their illness or disease. Cancer patients suffer from severe pain, and medication usually comes with serious side effects such as constipation, nausea, and vomiting. The palliative team would assess Mr. J.’s pain level and determine the most appropriate medication for him. If Mr. J. continues to exhibit signs of hypoxia, the palliative care team could provide the necessary equipment to keep his oxygen levels from declining further. Improving Mr. J.’ symptoms will directly improve his quality of life, plus accomplishing his daughter’s wishes of making him more comfortable. In addition, palliative care addresses symptoms of depression, anxiety, and stress by providing counseling services and support to the patient and their family. In this case, I believe the daughter would benefit from palliative care for emotional support while she is coping with her father’s illness.

The cost of healthcare services is another added stress that the family has to take on. Many times, the physicians will continue to order tests and medications so the family sees them attempting to do all they can to save their loved one. In many occasions, the physicians know that no matter what treatment plan they implement, nothing will reverse the course of the disease, but still they feel pressured to keep ordering more interventions. All these unnecessary treatments end up costing a fortune and the family is overwhelmed with the bills and hospital statements.

Palliative care has shown to reduce the cost of treatments and the financial burden that families go through and provide a treatment plan that has shown to be of a more positive intervention for the patients. In some cases, palliative care has extended the life of many terminally-ill patients and improved their mood and understanding of the disease. This has led to a better attitude towards life itself and a more positive response from the families as well.

Discussion Questions 2

The first potential barrier for Mr. J. and his family will most likely be explaining what palliative care consists of, its benefits and limitations, as well as the associated costs versus other treatment options. Many patients and/or their families have never heard of palliative care, and some only relate it to end-of-life care and advance directives type of conversations. Mr. J.’s daughter will most likely want to know how palliative care would be implemented into Mr. J’s ongoing medical care, how it would be different from current medical interventions, and specifically how it would benefit her father.

Second barrier would likely be the idea that if they accept palliative care, then their ongoing medical treatments and interventions will stop completely. Mr. J.’s family comes from a Hispanic cultural background, and Hispanics tend to equate aggressive treatments to better prognosis. Generally, Hispanics tend to avoid difficult conversations about the prognosis of the disease and steer clear from discussions involving advance directives. A common sentiment is to keep their family member on a ventilator as long as possible versus letting them go.

A third barrier consists of the idea that pain medication can be too aggressive and can potentially turn the patient into an addict. In this case, Mr. J. has metastasis to the femur and his non-verbal behavior has suggested that his pain is not being managed appropriately. Mr. J. is suffering, as evidenced by his increased agitation and confusion, and the appropriate goal should be to provide as much comfort as possible by first addressing the cultural barrier in regard to pain management.

Discussion Questions 3

Patient education should be the first strategy the nurse should implement with Mr. J. and his family. Palliative care is patient-centered, which means there will be a treatment plan tailored specifically to Mr. J.’s goals and needs The nurse should explain that palliative care is a team of healthcare staff consisting of physicians, nurses, social workers, and a support team, and along with Mr. J.’s current medical team, they come up with a plan of action on how to better address his needs. Palliative care focuses on improving the patient and his family’s quality of life, while still providing necessary medical treatments. Studies have shown that palliative care reduces the overall cost of medical treatment while providing more beneficial interventions to the patient and family.

Another strategy would be to contact specialized staff within the palliative team, to help the family navigate the complexities of the medical system and provide them with the necessary information to make educated decisions. In Mr. J.’s case, he suffers from dementia, as well as metastasis to the femur. Mr. J.’s caregivers will need assistance managing the changes of the disease process, such as an inability to move, loss of coordination, and the decline of sensory processing ability. The decline in health will bring about questions on available options and legal documentation that can potentially overwhelm the family unless there’s a support team ready to assist them.

In order to overcome the cultural barrier on the issue of pain management, the nurse would need to help refocus the family’s attention on the primary goal of palliative care, which is to provide comfort, alleviate symptoms, and enhance the quality of life as best as possible. This cannot be done if the patient is suffering with severe pain because of the wrong medication or incorrect dosage. The palliative care team, along with the patient’s current medical team, will reassess the patient and determine what would be the best treatment option. It’s important to let the family know that there are very few cases of patients going through end-of-life care that develop addiction problems, and the focus has to be on alleviating Mr. J.’s severe pain.

Discussion Questions 4

Since I come from a Hispanic cultural background, the biggest challenge for me will be to avoid making generalizations within the Hispanic culture that I have witnessed. I have learned that even within the same culture, you can find a very diverse set of beliefs. For me, topics of full code and keeping the patient alive through mechanical ventilation for the sake of extending their life are just not something that my family and I support, however I completely understand a family’s want to keep their loved one alive for as long as possible, no matter the cost.

I believe it will also be a bit of a challenge dealing with family members of a patient that has a Hispanic cultural background when dealing with providing and disseminating information.

I am aware that Hispanic families tend to leave the patient somewhat shrouded from their medical prognosis and treatment plan. The families tend to discuss the situation, come up with a plan, and then share the news or plan with the patient, possibly. There may be instances where the family doesn’t ever share the prognosis or plan for fear that it will dampen the patient’s spirit and worsen their condition.

Discussion Questions 5

I have experienced some of these cultural barriers within my own Hispanic family. My mother has reoccurring chest and low back pain, resulting in severe pain and routine trips to the emergency room. She believes that the doctor knows best, whatever their course of action would be. She feels that since the doctor has attended years of additional schooling and represents an elevated status within the community, then there is no second-guessing, he/she must know best. I find it difficult to get through to her to get a second opinion or seek out alternative treatment plans, but she holds firm to her cultural beliefs.

Additionally, my mother has been placed on a scheduled pain medication treatment plan. She is supposed to go in for shots into her spinal area every few months, yet she is deathly afraid of the shots and feels she will either become addicted or maimed somehow. As such, she skips her appointments and the pain inevitably returns. She suffers in bed unable to walk for several weeks until the pain becomes so unbearable that she forces herself to go get her injection.

If she were referred to palliative care, I believe the team would get to know my mother, and in doing so, they would learn of her fears associated with injections and work to find alternative way to provide her the necessary treatments. They would also alleviate her fear of becoming addicted to the pain medication since she will likely be on a scheduled dose regimen.

Discussion Questions 6

I feel that my personal perspective will actually be a benefit when dealing with patients from a Hispanic cultural background and their family. I will be able to anticipate some of the questions, hurdles, and struggles, and hopefully provide information and answers during these tough times.

I will be compassionate and draw upon my own dealings within my family and offer a perspective that only one from that cultural background can. It may seem miniscule, but I also believe that since I grew up in South America and I am fluent in Spanish, it would be a comfort to explain and converse with them in their native language. Familiarity brings comfort, and I would be able to provide that.

Part II

The Room

The location of where I would like to die might change drastically when my kids get older but for now, I would like to die in the comfort of my home. The scent of home will bring a feeling of serenity and peace. I would like my family photos on my nightstand, plants with flowers, my favorite bedding, and with the windows wide open as to allow the sun to shine bright upon me.

The Hat

I would like to have my husband hold my hand one more time as he has done so many times before. It will bring comfort knowing that after a lifetime together, he can now walk me down to the end of a fairytale love story. It would be great to have my dog next to me as well, to let me cuddle her one more time. At this moment in my life I wouldn’t want my kids to be close to me because that’s not how I would want them to remember their mom.

Panic Button

I don’t want to die alone; I don’t want to be left somewhere to suffer in pain without anyone hearing my calls. Also, I wouldn’t want to feel the suffocation of dying from shortness of breath. Most importantly I don’t want to die feeling like I wasn’t able to contribute to society or that my life was a waste of time.

References

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3. Esch, A. (2019, August 14). Living Well With Lung Cancer – Palliative Care Can Help. Retrieved from https://getpalliativecare.org/
4. Juarez, G., Ferrell, B., & Borneman, T. (1998) Influence of Culture on Pain Management in Hipanic Patient. Culture and Cancer Pain, 6(5),262-269

Palliative care is a term not unheard of. Bringing exposure to these two words are mainstream media such as television, or more conventional mediums in the form of written language in books and newspapers. Palliative care refers to helping those with chronic illnesses — usually nearing the end of their lifespan — live out their last days with dignity and improving their quality of life. It is when a group of people within the professional field work together to provide a comfortable space for patients to relax and to allow them room to come to terms with their conditions.

Essentially, respecting their dignity as part of the caring process is something that needs to be observed and maintained. This paper will explore the methods in which dignity — be it on the patients’ or caregivers part — is upheld throughout the process of delivering the patient’s care. It will look into the various existing studies that links dignity and the meaning it carries to patients, caregivers, relatives, and for the patients who require palliative care. The next few sections will provide a brief overview of the topic and existing research, followed by the relevance of the topic in Singapore, how it affects the quality of palliative care offered and finally, the solutions for any challenges faced.

The sense of personal dignity is something that we all have through each point in our lives. During transition into adolescence, dignity is mainly championed by our parents as they are responsible for us and we are dependent upon them. However, once we get older, our dignity becomes something we can control ourselves, that is, until we get older and senile. When approaching the end-of-life age, there are some other setbacks in the likes of serious illnesses that can impair a person’s dignity and essentially cause pain, despair and frustration to the patient and their family (Hospice Education, 2017). Palliative care aims to help both parties survive this period and end their lives in the best way possible.

Respecting their dignity involves making an effort to address the patients’ needs and wishes. Dignity is the lifelong need that is vital to any person’s welfare and their sense of worth and respect. With the loss of control over their dignity, it is imperative that hospices know how to take care of a patient without making them feel like their dignity is lost.

There are some key aspects of palliative care and respecting dignity that needs to be considered (Samaritan, 2015). For example, respect. This includes the mutual respect between people and the respect for privacy as well. It is the way that caregivers deal with the patients that matters in this context. Next, autonomy. This refers to the power to choose what the patient wants. Ergo, being able to be independent – something that is a struggle for many people of that age. Adding on, empowerment, which comprises of traits such as self-esteem, self-pride and modesty. The patient needs to be able to feel dignified and stand firm and strong despite their condition. Last but not least, communication, that in which is being able to understand information, both verbally and non-verbally, is something that they struggle with. They feel the need to be understood, and rightly so.

Dignity is important in palliative care setting as it is a form of respect towards patients and it gives them a say in decision making even when they are nearing end of life. The question of how their dignity is preserved can be answered through a number of ways, citing: physical needs, emotional needs, spiritual needs, social needs and family needs. Each of these can be controlled by their families and other caregivers that can help maintain their dignity at the end-of-life stage (WHO, 2018).

1. Emotional needs. To preserve their dignity, it is important to communicate with patients, listen to them and to sympathize with their feelings. It is also important to involve them in important decision-making so that they have a say in choosing and receiving the care they want and need.
2. Physical needs. This is the controlling and regulating of the patients’ pain and other symptoms like nausea and shortness of breath. The hospice caregiver needs to ensure that the patient is in the right environment to get dignified care.
3. Spiritual needs. For many people approaching the end of their life, spirituality is important, whether they are religious or not. This is characterised by them wanting to spend time with you in order to understand their life, identity and calling.
4. Social needs. This can promote dignity and can be done simply via activities like allowing a patient to control their finances and doing activities that make them feel happy.
5. Family needs. The caregivers are often trained to take the family’s needs into account as well. This will help maintain the dignity of the family during the illness and after death by providing social and emotional support.

Over the years, younger generations have been depending on palliative care to take care of their parents in hospices and old nursing homes on behalf of themselves. In Singapore, even as an individual is placed in palliative care, dignity is widely regarded as a crucial aspect. A study was conducted in Singapore to explore how dignity is demonstrated in palliative care. Through qualitative interviews with advanced cancer patients, it was determined that their experience of dignity was dependent upon three factors: social, organizational, spiritual. The study determined that apart from needing support from their friends and family, they also needed a good healthcare system, welfare organization and private sector support, as well as being able to observe the existing cultural and religious belief systems (Lee, Ow, Akhileswaran, & Goh, 2013). All the aforementioned are what helps to uphold a patients’ sense of dignity throughout their hospice stay.

There are many influencing factors that determines the importance of dignity whilst providing palliative care. Two key factors which can influence how well dignity is preserved at the end of life stage includes promoting self-respect and correspondingly, treating the patient with respect. These are both aspects that can be translated into the palliative care process. In most cases, the focus of palliative care is on prolonging life and symptom control rather than on wholesome and holistic care. As such, it would be beneficial for the hospice or caregiver to consider physical, emotional and spiritual needs of the patient throughout the palliative care process (Kennedy, 2016).

A study was conducted with 20 patients who were admitted to coronary care units and out of them, 5 were selected for purposeful sampling to participate in semi-structured in-depth interviews. They used qualitative data analysis methods and determined that in most cases, the degree of care results from the human environment and the physical environment. Therefore, the holistic care process has to include being able to meet the needs of the patients, both in the hospital and after discharge. These were the key themes that emerged in the study, along with the need for patients to have a sense of security and a good, effective relationship between the patient and the nurse (Borhani, Abbaszadeh, & Rabori, 2016).

Locally, there are programmes that are already in place to assist patients and their loved ones that are receiving palliative care. One programme implemented is the Temasek Cares- Programme Dignity, a pilot palliative home-care programme for advanced dementia patients. It has helped family members anticipate changes in care and providing solutions on how to alleviate significant distress of the patient. For example, using therapeutic touch to calm the patient down when they are agitated. Also, placing things that the patient likes around him/her can help to reassure them and reduce distress. This has enabled the caregivers to better manage patients.

On a global context, a study conducted by Rome et. al. of which its main goal was relieving the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients. These are some factors that tends to be neglected when taking care of patient’s nearing the end of life; therefore something Singapore can take into consideration when implementing palliative care.

The main challenges that are faced in providing palliative care includes the development of a national policy or a specific regulatory framework, of which includes resource allocation, culture building, collaborative policy making and interdisciplinary teamwork. By having a national policy, it caters to a widespread of needy people.

For instance, in Singapore, Government subsidy is available through means-testing. The level of subsidy is mainly determined by the household monthly income per person. In addition, Medisave can also be used for palliative care services. With the help of the policy, it has made healthcare cost much more affordable.

Another challenge is the training needed for workers and also public education. In Singapore, it has only been recently that people have started to understand how to deal with people approaching end-of-life. There needs to be professionals who understand what palliative care is about, and more crucially, possess the necessary training to carry it out. This is also something that is obligatory for the policy makers, health professionals and the family as a whole. Those involved needs to be informed of the way they can impact the palliative care system in Singapore using the existing systems or more (Lucas, 2013).

Another challenge that exists when ensuring that the patients’ dignity is being respected is the pain control factor. For diseases like cancer that can get extremely painstaking and unpleasant for patients, it is significant that it is identified as a primary symptom as well. Managing and maintaining dignity then, would be through providing pain relief that is available to all people.

With specific reference to Singapore, many reports indicate that the country officials have taken steps to ensure that palliative care is more available to people. Their new policy ensures that patients do not have to go for the most expensive options and that they can afford the palliative care at any price point. The country has decided to provide continuous residential services in the Healthcare Services Bill that would be able to regulate with more clarity the continuity of care to the patients and generally address the wider issue of quality care for palliative care (Rashith, 2018).

Some key solutions for the challenges stated earlier can be having more family centered care, which includes workshops for the families on how to deal with their relatives who are suffering with various diseases at the last stages of their lives (Ho, Luk, chan, & Ng, 2015). This goes hand in hand with the collective idea that highlights the importance that compassion plays in preserving the dignity of patients in Singapore and other areas.

In order to evaluate the effectiveness of the proposed strategies, I would recommend conducting a questionnaire to be sent to the family members of the patients to evaluate whether the workshop has been helpful in guiding them on coping with the fact that their loved ones are nearing the end stage of life. Questions asked in the questionnaire may include enquiring whether the workshop has been able to allow them to communicate better with their loved ones, and if not, how else they can improve; how much the workshop has taught them to recognise symptoms and curb the pain. Feedback would be collected after a one-month trial to evaluate whether the workshop’s tips are helpful, and if it isn’t, the strategies will be re-evaluated and necessary changes will be made.

Palliative care and the issue of dignity is something that needs to be considered with utmost importance. As per the research conducted, both in Singapore and in other countries, the feeling of dignity is universal. Patients approaching end-of-life wants to feel valued, dignified and loved. Despite the many challenges, there is a breakthrough in the sense that there have already been many measures put in place to improve the state of palliative care whilst respecting and upholding dignity as well. Some solutions have included training opportunities for caregivers to learn how to treat palliative care patients better, and to improve family relations. Patients need to feel respected and heard, and not treated as though they are dying, with no respect for their wishes. All these factors in providing a warm and comfortable environment for patients to live out their days in peace, with respect and dignity.

References

1. Borhani, F., Abbaszadeh, A., & Rabori, R. (2016). Facilitators and Threats to the Patient Dignity in Hospitalized Patients with Heart Diseases: A Qualitative Study. International Journal of Community Based nursing and Midwifery, 36-46.
2. Chochinov, H. (2002). Dignity-Conserving Care—A New Model for Palliative Care. Perspectives on Care at the Close of Life.
3. Enes, S. (2003). An exploration of dignity in palliative care. Palliative Medicine.
4. Ho, A., Luk, J., chan, F., & Ng, W. (2015). Dignified Palliative Long-Term Ca. American Journal of Hospice and Palliative Medicine.
5. Hospice Education. (2017). Seven Ways to Maintain Patient Dignity at End of Life. Cross Road Hospice.
6. Kennedy, G. (2016). The Importance of Patient Dignity in Care at the End of Life. Ulster Medical Society, 45-48.
7. Lee, G., Ow, R., Akhileswaran, R., & Goh, c. (2013). Exploring the experience of dignified palliative care in patients with advanced cancer and families: A feasibility study in Singapore. Progress in Palliative Care, 131-139.
8. Lucas, S. (2013). Palliative Care: Issues and Challenges. WHO.
9. Rashith, R. (2018). Singapore’s move to ensure palliative care isn’t disrupted for patients is financially sound: American expert. Singapore: Straits Times.
10. Rome, Robin B, et al. “The Role of Palliative Care at the End of Life.” The Ochsner Journal, The Academic Division of Ochsner Clinic Foundation, 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3241069/
11. Samaritan. (2015). Defining Dignity in End-of-Life with Hospice Care. Samaritan NJ.
12. The Care Journal : Dying with Dignity. (n.d.). Retrieved from https://www.temasekfoundation-cares.org.sg/journal/6/dying-with-dignity.
13. WHO. (2018). Palliative Care.

PICOT

Do adult patients with cancer pain (p) feel less pain when receiving palliative care from the palliative care team (i) if compared to conventional care practice (c) in terms of pain intensity reduction and improved pain management (o)?

• P: Patients with cancer pains
• I: Palliative management and consultations
• C: Conventional care practice (no palliative care whatsoever)
• O: Reduced pain strength and enhanced pain management
• T: This parameter is not required for this study.

Statement of the Problem

The problem revolves around the provision of care to palliative cancer patients and their overall psychological and physical condition. It is safe to say that this particular population is exposed to several health issues that adversely impact their state and seriously downgrade their resistance to depression and other mental health issues (Matzo & Sherman, 2014). Within the framework of this research, it is expected to evaluate the benefits of a palliative care team and their influence on patient outcomes. The researcher is certain of the fact that the social and emotional needs of palliative patients with cancer will be met as a result of the conducted research (Becker, 2015).

By addressing the issue of palliative care of cancer pains in patients, the researcher expects to answer the question of whether the developed practitioner-led intervention will turn out to be effective. (Matzo & Sherman, 2014). This problem is rather relevant for the existing health care environment because it is pivotal to identify the best way to deal with pains in palliative cancer patients and facilitate their living through the proposed intervention.

Connection to Specialization

The problem of implementing this particular practitioner-led intervention is inextricably linked to the area of my specialization because assembling a palliative care team of practitioners is hypothetically expected to be an effective instrument in helping palliative cancer patients to deal with their pains (Melnyk & Fineout-Overholt, 2015). Employing this project, the partakers will improve professional skills and expand their knowledge base in terms of mitigating pains associated with cancer.

The existing literature in the area also contributes to the connection between my specialization and the proposed intervention as there are issues that are currently insufficiently researched, and there is a need to generate more evidence (Becker, 2015). Also, by assembling the team of palliative care professionals, the researcher expects to address several issues inherent in nursing leadership practices and management approaches.

The Evidence-Based Nature of PICOT

The evidence-based origin of the practice question stated at the beginning of the paper can be supported by research in the area that claims that palliative care seriously affects the patients’ perceptions of pain (Matzo & Sherman, 2014). Also, the researcher expects to find a direct dependency between the outcomes in palliative cancer patients that do not involve serious pains and the implementation of the proposed practitioner-led intervention concerning the palliative care team. The evidence-based nature of the PICOT and the research project as a whole is anticipated to generate positive outcomes in the specified population (Moyle, Parker, & Bramble, 2014).

The implementation of the planned intervention based on Hopkins’ nursing evidence-based practice model will improve management practices at the healthcare facility and generate evidence in terms of the cost-effectiveness of the project and the patients’ feedback. The evidence-based origin of the research question is also supported by the positive outcomes that were found in the relevant literature on palliative care teams in general (Becker, 2015). The researcher believes that the implementation of this practitioner-led intervention will positively affect the department and help to validate the previous findings in the area in addition to the hypotheses of the study.

References

Becker, R. (2015). Fundamental aspects of palliative care nursing: An evidence-based handbook for student nurses (2nd ed.). London, UK: Quay Books.

Matzo, M., & Sherman, D. (2014). Palliative care nursing: Quality care to the end of life (4th ed.). New York, NY: Springer.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer Health.

Moyle, W., Parker, D., & Bramble, M. (2014). Care of older adults: A strengths-based approach. Port Melbourne, Australia: Cambridge University Press.

Stakeholders: Definition

Seeing that the study is aimed at researching the opportunities for improving palliative care for adult cancer patients, palliative care nurses should be viewed as the key stakeholders. Particularly, the identified population will benefit extensively from the efforts of the study participants that will help them control the patients’ response to painful experiences. Furthermore, the nursing staff, in general, can be viewed as essential stakeholders of the research. Nurse practitioners, physicians, therapists, labor unions, etc., can be deemed as the stakeholders since the outcomes of the study affect them directly, too.

Stakeholders’ Roles in the Organization

When considering the role of the said stakeholders in the organization, one must mention the fact that the nursing g staff in question performs a variety of roles, from administrative to providing care and guidance to educating patients about their disorders. Therefore, the stakeholders’ roles are numerous and essential to the general level of patient outcomes in the context of the hospital.

Converting People to Champions

High level of commitment and accountability are the qualities that define champions in research (Spalding, Stikes, Sparks, Myers, & Logsdon, 2016). Therefore, to compel the participants of the study to become champions, one should foster qualities such as responsibility in the target audience. As soon as the research participants develop the necessary skills, one should promote them to champions by providing them with additional accountability. Thus, the sense of involvement together with the concept of responsibility will have to be encouraged among the target population. Consequently, the identified participants will become the champions that will help move the study forward, therefore, helping it become a success.

Potential Barriers

It should be noted, though, that some limitations may pose a threat to the success of the study. The potential barriers include the time constraint, the possible lack of engagement among the nursing staff, the issues associated with the employee shortage in the nursing environment (e.g., the notorious burnout statistics that points to the busy schedule being the key problem triggering a drop in nursing quality levels, etc.) (Bogaert, Dilles, Wouters, & Rompaey, 2014). However, the issue associated with the lack of engagement among the nurses and, therefore, the subsequent drop in the quality of the services provided by them should deemed as the primary area of concern.

Strategies for Managing the Barriers

The barriers in question can be removed by introducing the tools that will allow for efficient time management, as well as the active engagement of the staff members into the process of meeting patients’ needs. The time issue will need to be handled by reconsidering the current schedule, as well as suggesting that the nurse administrator should redistribute roles and responsibilities among nurses in a more homogenous manner. As a result, a reduction in the burnout rates and, therefore, a rise in the engagement levels among the nurses can be expected.

Furthermore, the significance of new knowledge and skills acquisition as part and parcel of continuous professional growth will have to be outlined to the nurses.

Change Theory

The Herzberg two-factor motivation theory seems to be the most efficient tool for promoting change in the target environment. Helping illuminate the possibilities to the staff members, the theory in question compels them to acquire the necessary skills and knowledge that will, later on, guide them to self-directed learning (Holmberg, Caro, & Sobis, 2017).

References

Bogaert, P. V., Dilles, T., Wouters, K., & Rompaey, B. V. (2014). Practice environment, work characteristics and levels of burnout as predictors of nurse reported job outcomes, quality of care and patient adverse events: A study across residential aged care services. Open Journal of Nursing, 4(5), 343-355. Web.

Holmberg, C., Caro, J., & Sobis, I. (2017). Job satisfaction among Swedish mental health nursing personnel: Revisiting the two-factor theory. International Journal of Mental Health Nursing, 1(1), 1-12. Web.

Spalding, G., Stikes, R., Sparks, K., Myers, J., & Logsdon, M. S. (2016). Research Champions: An initiative to improve use of research evidence in nursing practice. Journal for Nurses in Professional Development, 32(2), E1–E5. Web.

Palliative care, also known as comfort care is a significant care given to people with critical illnesses (Lugton & McIntyre, 1). It prolongs their life and relieve from pain affecting them and their intimates. Its goal is to prevent the symptoms and side effects of an illness besides treatment as early as possible. Palliative care is usually given systematically, putting into consideration psychosocial and spiritual needs of the patient and family. Routine for administration of palliative care should be provided by health care professionals.

The complexity of the situation usually determines if the condition is to proceed to palliative care. It begins from the time of diagnosis of life endangering illness and will continue until death and family grief period. It involves helping the patient relieve the suffering and making their families understand the conditions for change in patient. The effects of these changes should be made clear to them, and this will assist in the future care.

For this succeed, attention is required together with exceptional communication skills. Health professionals should pursue an illness from its early stages of diagnosis to prevent it from advancing. A complex diagnosis proceeds to palliative care (Meie, Isaacs & Hughes, 141). The basic elements of palliative care are pain, and symptom assessment and advanced care planning management.

Palliative care specialists should have the necessary competence in handling disagreement cases (Lugton & McIntyre, 3). In some of them, they are supposed to make decisions on whether to agree with the patients’ opinions or their own opinions (Meie, Isaacs & Hughes, 297). In such cases, the decision taken by the specialist depends on his/her competence. The decision starts from the point where a chronic case is to proceed to palliative care.

Usually, disagreement occurs between them and patients on whether cases will proceed to palliative care or aggressive treatment. Both parties should be able to reach a consensus, with the decision provided by the patient voluntarily. However, there are some cases where there is disagreement, and in such cases, the physician should balance the expected benefits with the risks of patients’ choice as compared to other alternatives.

In most cases, the physician is the decision maker due to patients, failure to make the right decision under that prevailing condition. The decision to be taken by the specialist should depend on the competency of the patient and values at stake (Meie, Isaacs & Hughes, 207). These values underlying standards of competence are promotion of individual well being of the patient and respecting their self determination.

Treatment should be stopped when the condition of the patient is complicated and irreversible. Advancement to palliative care can also occur if the treatment given to the patient is not working and causes a lot of pain to the patient. It can start immediately after the diagnosis of the condition. This implies that palliative care can be provided together with the treatment.

Decision on whether to offer palliative care should be done by both the clinician and the patient. They should be able to agree on such cases. If the patient is not able to make that decision, then it becomes the role of the clinician to do so. In some cases, a family member may demand for aggressive treatment to be given to the patient or may disagree among themselves (Hallenbeck, 163).

The ability to resolve such Medicare conflicts depends on the clinicians’ competency. An effort should be made towards enabling the families understand the suffering inflicted on the patient. Aggressive treatment could be causing a lot of pain on the patient.

This raises a concern on the need to review health care policy and ethics. It is evident in Schiavo’s case, which had a conflict between her husband and health professionals (Meie, Isaacs & Hughes, 179). The doctors’ obligation here is to help Schiavo from suffering, but her intimate feels as the doctor had neglected her. Other cases include Emilio Gonzales case, Hengla Wanglie’s case and Baby L’s case (Truog, 1).

These are few examples of futility cases, which involve disagreements and mistrust between clinician, and patients’ families. The success of a professional resolving such cases depend on communication skills and conflict resolution skills possessed by the physician (Lugton & McIntyre, 6). The obligation of the physician is to serve the interests of the patient and family equally (Lugton & McIntyre, 12). It is recommended that such ethical dilemmas involve hospital ethical committee.

Palliative care does not have a distinct payment insurance benefit. Usually, the cost of palliative care is covered with patients’ health insurance. The patients’ family members may be required to cover up the extra costs. Insurance programs have aided many people in payment of palliative costs.

People should be educated on the importance of joining them. In cases where a person is undergoing palliative care, it is the responsibility of community members to provide support to their family in terms of payment for premiums and psychosocially. It is also their responsibility to demand insurance programs to provide cover during palliative care.

Works Cited

Hallenbeck, James. Palliative Care Perspectives. London: Oxford University Press, 2003. Print.

Lugton, Jean & McIntyre, Rosemary. Palliative Care: The Nursing Role. California: Elsevier Health Sciences, 2005.Print.

Meie, Diane E., Isaacs, Stephen L. & Hughes, Robert. Palliative Care: Transforming the Care of Serious Illness. London: John Wiley & Sons, 2010. Print.

Truog, Robert. D. Tackling Medical Futility. N Engl J Med. Web. 357; 1-3.