Apply a Palliative Approach in Nursing Practice

History

Geoff Holder, a 52 year-old owner/operator of a pest control franchise, has been admitted to the medical ward. He was admitted from home via the emergency department, and arrived on the ward at 0200hrs this morning.

Geoff has a history of Diabetes Mellitus Type II which has been previously well controlled by diet and exercise. He was diagnosed with pancreatic cancer six months ago and underwent a Whipple’s procedure with initially good outcomes. Geoff lives at home with his wife and eight year old son: his daughter from a previous marriage lives with Geoff’s ex-wife and attends university, studying education. Geoff has increased contact with his daughter since his diagnosis and she has dinner / visits with his family at least once a week.

Geoff’s father died aged fifty in hospital from liver cancer, after a history of heavy alcohol and cigarette use. Geoff was twenty years old and recalls him experiencing significant pain before he died. Geoff’s mother has dementia and has lived in a residential dementia unit for two years. Geoff has limited contact with his only sibling, a brother who lives in Perth.

Since his diagnosis of  pancreatic cancer six months ago and after his Whipples procedure which initially was successful Geoff was able to continue working from home, but now is extremely fatigued, cannot undertake activities of daily living and has increased pain, his diabetes is also now  not well controlled.

He presented to the emergency department at 1800hrs for pain control and reluctantly consented to admission for review by the palliative care team today. He has not accepted community services, including community palliative care services, to date.

His medications from home (Ordine) have been brought in and are locked in the controlled drugs cupboard. He has an Acute Resuscitation Plan and is not for active resuscitation. His care has been managed by the GP since his discharge after the Whipple’s procedure.  

Since being on the ward he has had two episodes of break through pain (9/10) that he was given oral analgesia for, the first at 0230hrs of 5 mg of Ordine and another 5mg of Ordine at 0500hrs. This reduced his pain to a score of 4/10, but the pain continues to worsen. He says his pain score goal is to remain below 3/10. He has been too fatigued to mobilise to the toilet. His blood sugar level was 8.2mmol/L at 0600 hrs, and this is being checked three times daily.

He is for review by the palliative care team later in the day.

Vital signs: T 37.2, BP 108/70, P 110/regular, R 16, SpO2 98% on room air

Position supine, bed head at 45? and pillow propped behind right shoulder to lift him slightly

ID Band (UR: 106425, Geoffrey Ray HOLDER, 10 Luca Street, Brighton. DOB: 07.02.1960, Male)

Medications as per the medication chart are

Ordine (Morphine Sulphate) 1mg/1ml – order for 2.5-5mg PRN by Dr Mitchell

MS Contin SR 5mg tablets

Paracetamol (tablets) 500mg

IV bag 0.9% Sodium Chloride, running at 100ml/hr on infusion pump

Your team is looking after Geoff this morning. You need to get him ready for breakfast and check on his pain level? He is for review by the palliative care team later today.

There is concern about Geoff and his wife. He seems very angry about everything and staff are unsure why this might be particularly directed towards his wife. He has refused all offers for food and fluid overnight and is extremely focussed on controlling his pain so he can go home. He does not want to be here and has expressed quite clearly that he wants to die at home.  

As the symptoms assessment scale is basically a tool used to identify/measure patient health condition or symptoms that distressing the patient by using number from 0 to 10 ( 0 mean symptoms is absent and 10 mean patient is experiencing worst distressing pain). In consideration to the Geoff Case study he was experiencing moderate pain of score 4/10, in consideration to palliative care principles the area of concern are:

Pain management: Geoff was experiencing continuous pain which may affect both psychological and social aspect, considering this element the administration of drug on time is vital, which is evident in the case study as paracetamol and analgesia has given to the patient. Maybe to calm anxiety and fear of the patient the administration of adjuvants might be needed.

It is vital in palliative care to provide best care as per patient need, the team may consider option of providing at home as per patient preference (Mecardante et al., 2018)   though still ensuring that effective care is been delivered to the patient to manage the condition.

I will use effective communication and listening skills to ensure that Geoff comfortably rate the pain he is experiencing.

For example, Following mentioned question in Brief Pain Inventory Form are helpful in identifying the Geoff pain and area of concern.

1. On the diagram, Put an X on the area that hurts the most:
2. Rate your pain by marking ? the box beside the number that best describes your pain at its worst in the last 24 hours.

0 ? (NO Pain)  1 ?  2 ? 3 ?  4 ?   5 ?  6 ? 7 ? 8 ? 9 ? 10 ? (Pain As Bas As You Can Imagine)

3. Rate your pain by marking ? the box beside the number that best describe pain on average.

0 ? (NO Pain)    1 ?  2 ? 3 ?  4 ?   5 ?  6 ? 7 ? 8 ? 9 ? 10 ? (Pain As Bas As You Can Imagine)

4. In last 24 hrs, how much relief have pain management and medication has provided?

0% ? (NO Relief)    10%  ?  20%  ? 30% ?  40% ?   50% ?  60% ? 70% ? 80% ? 90% ? 100% ? (Complete Relief)

Brief Pain Inventory form is vital in understanding patient condition better (Alizadeh-Khoei et al., 2017)

As Geoff has said that the pain experience by him is around the scale of 4/10 which is considered to be a moderate level of pain experience by Geoff continuously and the goal is to reduce the pain below the 3, this continuous pain might have affected Geoff mental wellbeing as well, that is why he is agitated and angry about everything he refused food and fluid in last overnight which may adversely worsen his other underlying condition such as diabetes. Anxiety, anger, and fear might interfere with Geoff management of the condition hindering the treatment.

The key strategies that I can implement to address the pain are:

Identifying causes of the pain: identifying cause of pain help in better management of the condition (Alizadeh-Khoei et al., 2017).

Managing pain with medicine: giving pain relieving medicine, monitoring patient symptoms.

Managing pain without the medicine: I think using psychological therapy such as relaxation or cognitive behavioural therapy are supportive in changing how patient think about pain which in turn can improve the patient behaviour to manage the chronic condition. Mental wellbeing are very important part in effectively manage the pain and attaining desirable health outcome.

I will suggest Geoff some natural solution such as eating fiber, taking healthy diet and fluid, and include low to moderate level physical activity to treat constipation, also stool softeners or laxatives can be prescribed to treat constipation. As patient has diabetes issue the fiber supplement will help in treating the condition effectively. Poor diet is found to be one of the main reason of constipation and it can discomfort the patient (Wald & Talley, 2017), thus, suggesting both natural solution and medication can help in treating the Geoff condition effectively. 

Goal/action

Intervention/rationale

Evaluation

Lifestyle

The goal is to manage patient constipation and physical movement thorough ensuring adequate physical activity and healthy diet.

• Adequate low-moderate level physical activity, taking help of occupation therapist
• Healthy diet

This will help in in treating/managing Geoff constipation issue and will improve physical activity.

Social context

Involving Geoff in more community event to improve social connectedness to improve mental wellbeing

• Using therapeutic skills to inform Geoff about necessity/benefit of taking community service
• Involving Geoff in community event to improve mood and metal wellbeing will help in managing anger issue.

Improve Geoff mood and anger issue.

Emotional

Relieving pain

• Pain relieving medicine to effective treatment of the pain (Money & Garber, 2018), educating patient about the mechanism of medication and its effect to effectively monitor the medication and it will help in managing pain better
• Psychological therapy to improve the way Geoff think about the pain, as mental wellbeing and positive attitude is very vital in effectively treating the pain, thus, to ensure effective pain management improving psychological wellbeing of the patient will help in attaining good health outcome.

Pain management

Spiritual

Improve spiritual wellbeing through effective communicate the feeling with others, trust and think positively.

• Meditation/yoga to help patient to think positively and improve self-esteem, taking help of spiritual practitioner.
• Demonstrating therapeutic skills to ensure patient share this feeling comfortably so that effective care can be delivered.

Positive attitude benefiting both physical and mental wellbeing

My role and responsibilities as EN when planning palliative care for Geoff involves:

• Providing direction and instruction to care worker about the health necessity of patient, for instance, ensuring that worker are aware about deliverable to meet patient need and other vital obligations (Izumi, 2017)
• Communicating with family to ensure effective plan is made for Geoff
• Communicating and coordinating service delivery with GP and other palliative team members
• Conducting need assessment, and planning and reviewing care plan and procedure.

The other members who may part of interdisciplinary team are:

General practitioner: for day to day health care issues, prescribe medication for pain (Izumi, 2017)

Cancer specialist: oversee treatment to manage the condition and will manage some aspect of Geoff palliative care.

Psychologist:  help in managing emotions and will support in better mental wellbeing help in easing pain.

Spiritual care practitioner:  may discuss emotional issue, may connect patient to reflect on life.

Occupation therapist: occupation therapist can help in improving mobility.

Dietician: to help in drafting suitable diet plan to ensure healthy wellbeing. 

I will use therapeutic skills when communicating the stages of dying with Geoff and his family, I will inform the about the process and how it depend on different factors such as difference in personality, culture, progress of disease, and other factors, the dying process comprise five phases such as denial, anger, bargaining, depression, acceptance.  First phase is denial, in this phase patient react with denial, they refuse to believe test result, or doubt the treatment is been provided to them due to shock. The second phase anger, In this phase when patient is no longer can deny the imminent death, they become agitated and angry, and they show anger on their family and carer. In third stage, Bargaining, patient bargain with higher power in their religion to avoid death, they may ask spiritual advisor to advice how to avoid death, and begin praying to be accepted into afterlife (Lewis et al., 2018). In fourth stage, patient may suffer depression they refuse care, medication, show symptoms such as fatigue, self-harm, etc.  Fifth stage is acceptance where patient emotion become more stable and calm, patient reflect on joyful memories from the past, wish to spend more time with family.

The ethical concern that may arise from Geoff case study is end of life issues, as Geoff wishes to the way he want their lives to end. As Geoff wishes to go home and die there, the decision may distress the family or carer who may think the better care can be delivered in the hospital, thus, considering this issue health practitioners need to prepared to handle end-of life issue as well as other problems that may encountered in dealing with patient who may not be able to make rational decisions on their own (Black & Helgason, 2018). Thus in order to manage this palliative care team can provide comprehensive assessment and treatment of physical, mental, spiritual wellbeing to both patient and his family.

When caring for patient facing end of life care, it is vital to self-reflection, make strategies to manage emotional health, taking support from counsellor, or senior to manage the condition. (Black & Helgason, 2018).

• Taking help from counsellor or senior
• Balancing caring role with needs
• Self-care to ensure better mental and physical wellbeing, spending time with family and friend to improve mental wellbeing.

Self-care plan such as eating healthy, relaxing, looking up-to own health as well as colleagues health, communicating effectively and seeking professional support to ensure we look up to our own health when caring for patient facing end-of-life care.

The three point that I will reflect on during debriefing session regarding the care of this patient are:

• How person psychological wellbeing can be hindrance to care and how it may affect his family as well (Sabei & Lasater, 2016).
• Person need better approach toward the condition to ease the condition
• How involving patient in care plan will be beneficial at the moment to meet patient need, therapeutic skills can support in effectively care for patient.