The Department Of Nursing Nursing Essay
Faculty of Health Sciences
University of Malta
Nur 2209 Assignment
Charlene Sarah Vella
Palliative care is intended to provide what is known as a ‘good death’ this is often provided through hospice, an interdisciplinary team, patient and family centered program of total palliative care in the aim to provide and help the patient and the family members to live as good as possible through the dying process. Often the person who is dying is diagnosed whether Cardiopulmonary resuscitation (CPR) where artificial ventilation and manual external cardiac massage is used in case of cardiac arrest can take place, this is done by discussion together with the consultant and the family members, most of the time the patients come to an understand that tender love and care is the best option. Therapy is offered to the family as a family unit, to learn how to deal with the grief, the physical, the psychological, the social, and the spiritual effects on the dying persons, family members, friends and caregivers. Some patients have a fear on being a burden on others and family member other feel overwhelmed. This is where the nurse comes in to assess and listen to problems and fears, to be of assurance and to be the barrier between the patient’s needs, the family’s needs and the multidisciplinary team. To offer the best postmortem care, care for the body after death in a manner consistent with the patient’s religious and cultural beliefs.
A brief description:
Mrs. Mary Camilleri has pancreatic cancer which has metastasized to the liver. The consultant was supposed to have explained to MRs. Camilleri and her family that pancreatic cancer is a type of cancer that attacks the pancreas. The Pancreas is one of the largest organs in the body. It is found behind the stomach where it makes and releases enzymes into the intestines, these enzymes help the body absorb food such as fat. Here we can also find hormones. These hormones are insulin and glycogen which aid Mrs. Camilleri to control her sugar levels in the blood as these are made in certain cells that are found in the pancreas also known as islet cells. According to research there is no known cause of pancreatic cancer but due to having the mother suffering from the illness the three sons are to have regular blood samples taken especially of the renal profile, Lipid profile, liver profile, albumin, calcium and phosphate, correction calcium, estimated glomerular filtration rate (GFR), full blood count and erythrocyte sedimentation rate and also stool samples. These main blood tests would be beneficial to do in just in case, in prevention. Although it is known that pancreatic cancer is likely to be more common in women than in men the risk increases with age and is also passed down through families. High risk people are people who smoke, people who have diabetes, old age and people with reoccurring pancreatitis. Since pancreatitis has no symptoms it is often found in an advanced stage so cure can be difficult, all that can be done is treatment.
It is good for the family to know that some complications that may arise from pancreatic cancer are blood clots so it is important to have heparin or warfarin as long as it acts as an anti coagulant in the blood, depression due to mood swings from chemo therapy, infections because after chemo therapy the patient will become immuno suppressed since the chemo therapy will kill good and bad cells, pain management would be in order such as opioids or codeine painkillers, weight loss is also expected since the liver and the pancreas will not be able to digest food properly, chemo therapy does not help because it will create mouth ulcers and this will make it difficult for Mrs. Camilleri to eat, taste would be effected and sense of smell also as during treatment Mrs.Camilleri would go through phases where she would smell everything smelling bad. Prevention as to not complicate things Mrs. Camilleri is advised to stop smoking if she smokes and if her husband or sons smoke it has to be emphasized for them not to smoke near her of just before going to visit her because they will still carry the smell and this is not good. Mrs. Camilleri would be advised to change her dietary intake by eating more fruits and vegetables and also include fibrous products. Physical exercise would also be beneficial not rigorous exercise even a short walk would be beneficial to her health; if the family would join her it would be better.
Principles for palliative care to address the patient’s needs:
The principles for palliative care where made to fit the patient’s needs and they focus on family centered care, as it is very important for the patients well being in order to have a "good death" (WHO, 2002) to be surrounded by the family and be pain free as much as possible.
The first principle is for pain relief and other arising symptoms that can cause the patient to feel distressed and anxious. In this case Mrs. Camilleri is in her last stage of cancer and she will need a lot of pain medication as she has already presented with increasing abdominal pain this indicates that she will need strong pain reducing medication.
The second principle is to promote life and try to as much as possible help the family and the patient understand that dying is a process that everybody goes through. Since Mrs. Camilleri and her family are aware of her diagnosis and poor prognosis the next step is to help the family go through acceptance together. It is important for the doctor to give the family a time limit and tell the family that this may be more or less and then help the family go to counseling together have weekly sessions to talk about their fears, questions that may arise, talk about the funeral plan it together maybe, the mother can have a list that she wants such as dress code or choice of music, it is very important for the whole family to go through this together. The mother and father can opt to have alone time to discuss certain issues settle certain problems or forgive each other for past situations. This step is a very important step and will in turn help with the grieving process.
The third process intends not to hasten or postpone death. I am sure that when Mrs. Camilleri and her family got to know her prognosis they got an idea of a time frame so that they could plan out her wishes what she really wants to do together with her family before the allotted time runs out. A good planned palliative care will allow enough time for everything to be done and also to plan out everything so that Mary and her family would have peace of mind and not worry about extra things.
The fourth process combines the psychological and spiritual aspect of the patients care. The nurse or caregiver would by now gotten very close with the patient and her family and would know what the patients needs are. The nurse can give ideas to the family to get closer to try and do relaxation exercises together, like yoga, go to church together, go to counseling sessions as a family unit, maybe they like to draw and can draw together as these things can also elevate pain and at the same time they would be helping each other to bond and cope more with the future.
The fifth process is to offer support to the patient and her family as to not give up doing things they love together or hobbies that the patient might have until that day where end of life may occur. This is very important, support from nurses and caregivers are very essential. Kind words of reassurance can give strength so that on that day Mary would go out of her room or bed and be active even if she is in pain she would find the strength and courage to go out. Constant support and encouragement cannot be emphasized enough especially with these type of patients because they will need twice as more than the normal patient because depression and sadness can hinder their personalities at a much higher risk than normal patients.
The sixth process is to offer support and help to the patient and their family in order to continue living during the whole process of the illness and also after when the bereavement process begins. Usually people go through five stages of bereavement which are denial and isolation; this is at the beginning of the prognoses when Mrs. Camilleri and her family had found out that the illness is terminal. Anger, this anger can be towards god or something that they believe in, towards the doctor, towards themselves depending on the character and the individual. Bargaining, this could be with God or a higher power, with luck or something they believe in grasping on all hope just to keep the relative alive. Depression, this is when the person starts to face reality and understand that there is nothing they can do that death is going to happen and time has to be spent to the best possible way. Acceptance is the last stage, this is where the person accepts the faith presented upon him/her and in a way try to help the family accept it too. Not everybody gets the chance to go through all the stages as time may run out before reaching this final stage of grief the peaceful acceptance of death. Also some people when they go through death especially death of someone very close to them might be inspired to evaluate their own feelings of mortality. It is important that Mrs. Camilleri and her family get the appropriate help and support from professionals so that as a family unit they can go through these five stages and really and truly have a peaceful death.
The seventh process is very similar to that of the sixth process that is to use a team approach to address issues of bereavement of the patient and her family as it is very essential to have support of your family through a time like this and a good death cannot be achieved by the nurse or the doctor alone it is a team effort.
The eight process is to enhance the quality of life which in turn may positively influence the course of the illness. Through this tough time Mrs. Camilleri will need a lot or moral, spiritual, mental, support. Be it from friends, family, caregivers and other professionals involved in her illness so on. Mary is very lucky that she a has a loving husband and three sons who offer their full support to her and her illness and this is what helps her to move on and fight day by day.
The ninth and final process of end of life care is usually done in the beginning of the illness together with other sources of medication such as chemotherapy and radiotherapy, and also includes other means of investigations such as blood tests and biopsy samples to better understand the illness thus providing a better prognosis and medication to ultimately prolong life.
The processes for a good death puts emphasis on the quality of life not quantity, it tries to help the family see that dying is a normal process that every individual has to go through it is just that their experience is different from others due to the circumstances they are in. This process helps us as health workers to view the patient holistically and not only look at the medical side of things. It is thus very important to follow a good nursing process together with the multidisciplinary team. In this way we can have a better understanding on what the patient and the family go trough in the dying process thus as nurses we can help more and better ourselves in our profession.
Assessing and managing Mrs. Camilleri’s uncontrolled symptoms:
We know that Mrs. Camilleri is suffering from advanced pancreatic cancer and that it has metastasised to the liver. Since she has been complaining of increased abdominal pain and nausea we have to assess and control her symptoms. Due to the matastesised cancer Mrs. Camilleri is more likely to be suffering from bowel obstruction this could be that the chronic intestinal pseudoobstruction (CIP) which is found to be couse by diabetes mellitus and or surgeries that had been done previousely in the gastric tract and other neurological disorders. These circumstances may contribute and effect extrinsic neural control to viscera. It is also found that vagal dysfunction is present in a good number of patients with CIP which are prognosed with diabetes or neurological dysfunction. It can also be that Mary could be suffering from paraneoplastic pseudoobstruction which is another cause such as inflammatory edema, fecal impaction, constipating drugs (such as opioids, anticholinergics..) and dehydration are likely to contribute to the development are likely to contribute to the development of bowel obstruction, abdominal pain and nausea. There are studies that state that when there is bowel obstruction there are usually three instances that contribute to this type of obstruction. These are the accumulation of gastric, pancreatic and biliary secretions that are a potent stimulus for further intestinal secretions. Loss of absorption of water and sodium from the intestinal lumen and an increase in secretion of water and sodium into the lumen as distension increases. When these happen we also find that the reabsorption of the gastrointestinal tract will be left with a decrease of fluids and electrolytes. Whereas in the pancreatic, biliary and gastrointestinal secretions tend to accumulate in the bowel above the obstruction and the volume of secretions tends to increase following intestinal distension and the consequent increase in the surface area thus producing a vicious circle of secretion to distension to secretion. Depletion of water and salt in the lumen is considered the most important toxic factor in bowel obstruction.
When caring for cancer patients especially those that are in their end stage of care like Mrs. Camilleri it is important to keep in mind that compressions in the bowel lumen develop at a slow rate and many a time these remain partial. The first symptoms include cramps in the abdomen, nausea and vomiting and also abdominal distention which are generally present occasionally and resolve on their own. When this happens we find that more times than not they are followed by gas or loose stools. As nurses we can evaluate Mrs. Camilleri’s symptoms of nausea and pain in her abdomen by observing her frequency of pain, asking her to number her pain from a scale of one to ten or by stating verbally he pain measure. When assessing Mary who is suspected of having malignant bowel obstruction (MBO) there are other criteria to keep in mind such as, other causes that could be causing Mrs. Camilleri to feel nauseated, maybe vomiting and constipated. Are there any metabolic abnormalities. The type and dosage of the drugs Mrs. Camilleri is taking. Her nutritional and hydration status. Her bowel movements and the presence of overflow of diarrhea. The presence of abdominal fecal masses, distension to all the abdomen or above the obstacle, ascites as well as painful site. The presence of feces in the rectal ampulla ( rectal exploration).
Management for Mrs. Camilleri’s symptoms would be one of the greatest challenges for physicians as the management has to be very individualized depending on where the illness has arrived, the prognosis and whether it is possible to further with antineoplastic therapies and also depending on where the patient has arrived with choices, appearance and strength. If the patient has little of no chance of cure as in the case of Mrs. Camilleri discomfort and pain have to be balanced together with the need to as much as possible simplify the care. Surgery will remain the primary treatment in these patients’s. Palliative surgery would be considered when relief from symptoms such as nausea and abdominal pain is not obtained within 48-72 hours after decompression with a nasogastric tube has been implemented.
If Mrs. Camilleri and her family would not want to go through surgery than venting procedures should be the next option these are usually used on patients who cannot afford to have surgery. Usually the treatment consists of drainage using a nasogastric suction associated with parenteral hydration. This type of treatment decompresses the stomach and or intestine and corrects fluid and electrolyte imbalance before surgery or while a decision is being made.
The multidisciplinary team together with Mrs. Camilleri and her family would opt for self expanding metallic stents which are very useful in the management of patients with advanced metastatic disease who are at poor surgical risk. Malignant duodenal obstruction is most commonly secondary to neoplastic invasion but more frequently due to extrinsic compression by lymphadenopathy. In patients unfit for general anesthesia, surgery or laparoscopic drainage procedures such as gastroenterostomy internal stenting of the lesion may be indicated.
Pharmacological management is very important for Mrs. Camilleri these will be the first line treatments in controlling her uncontrollable symptoms and will offer some relief until further decisions on what her treatment would consist of would be. In this type treatment the main focus would be for the pain, nausea, vomiting and other symptoms excluding the nasogastric tube. If a central line has been previously inserted this can be used to administer drugs for symptom control. Continuous subcutaneous infusion of drugs using a portable syringe driver allows the parenteral administration of different drug combinations, produces minimal discomfort for the patient, and is easy to use in a home setting. Route of administration is very important for palliative patients and who are suffering for the symptoms as presented in Mrs. Camilleri. In most patients with these symptoms oral administration is not suitable and alternative routes have to be considered. Most of the recommended drugs can be administered in association via parenteral continous infusion. To relieve Mrs. Camilleriy from her continuous abdominal pain opioid analgesics via continuous subcutaneous or intravenous infusion are necessary in most patients. Anticholinergics may be administered in association with opioids to control colicky pain that is stomach pain. The sensation of nausea which can lead to vomiting can be managed with drugs such as anticholinergics such as scopolamine, butylbromide, glycopyrrolate and or octreotide which reduce gastrointestinal secreations. Antiemetics acting on the central nervous system alone or in together with drugs to reduce gastrointestinal secretions. Corticosteroids can also help by reducing peritumoral inflammatory edema.
The last step for managing Mrs. Camilleri’s symptoms would include hydration and parenteral nutrition which would be suitable for this type of patient since she has inoperable bowels. The amount of fluid to be administered has to be assessed very carefully because high levels of intravenous fluids which may result in an increase in bowel secretions, thus making it necessary to keep a balance between the efficacy of the treatment and the side effects such as increased vomiting and abdominal distension and pain. Mrs. Camilleri could also experience dry mouth and thirst these would be independent on the quantity of both intravenous or oral hydration. However the intensity of nausea would be significantly lower if Mary would be treated with more than 1 L/day of parenteral fluids. Research has found that intravenous hydration can be difficult and uncomfortable for patients with end- stage cancer, so it should be reserved for patients who have a central venous catheter.
In conclusion to my research I can say that it is necessary to reach an outcome of survival rate in Mrs. Camilleri so that together with herself and the family appropriate decisions on the therapeutic outcomes can be made. Meanwhile medical treatment by continuous subcutaneous or intravenous administration of opioids, corticosteroids, anticholinergic drugs, octreotide and antiemetic drugs can be an effective approach for controlling abdominal pain, nausea and vomiting. It is very important that the efforts of the multidisciplinary team would be aimed at both controlling of symptoms and other holistic aspects of the patient such as the psychological distress and spiritual concerns. The patients in this case Mrs. Camilleri is to always be viewed holistically first and in every decision it is of upmost importance to include the family in every decision and procedure.