Chronic Pain Management and Palliative End of life Care Case Case Study 2022

Running Head: CHRONIC PAIN MANAGEMENT, PALLIATIVE AND END-OF-LIFE CARE.
CHRONIC PAIN MANAGEMENT, PALLIATIVE AND END-OF-LIFE CARE.
(The Gibbs Reflective Cycle).
Name
Institutional affiliation

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Contents
Description..................................................................................................................................................3
Introduction.............................................................................................................................................3
Principles that govern the care of patients...............................................................................................3
Feelings and Evaluation..............................................................................................................................4
Pharmacological and evidence-based complementary therapy................................................................4
Acupuncture........................................................................................................................................6
Hypnotherapy......................................................................................................................................7
Aromatherapy......................................................................................................................................7
Reflexology, Tai chi and Yoga............................................................................................................8
Mental health considerations...................................................................................................................8
Ethical and Legal issues in advanced care planning................................................................................9
Analysis.....................................................................................................................................................10
Conclusion.................................................................................................................................................10
Action Plan................................................................................................................................................10
References.................................................................................................................................................11

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Description
Introduction
Ensuring that a patient is comfortable as they undertake their treatment is the very definition of
nursing. It is a very delicate process, especially when the patient is suffering from a terminal
illness. Patients with terminal diseases undergo a lot of pain, both physical and psychological. In
the case of Michelle, physical pain is brought about by the breast cancer itself. She says that
undergoing the cancer treatment was very difficult. She says that the revelation that she had
breast cancer turned her world upside down (media.pcc4u.org). The psychological pain in this
case begins with the loss of hair. Further, Michelle is devastated by the news of her relapse
(media.pcc4u.org).Managing this pain is the one way of enabling them to lead a life with some
semblance of normality. Several tenets govern how this matter is approached. Understanding
these principles accords physicians with the knowledge needed to adequately care for their
patients. Pain management for terminal illness can be palliative or end-of-life care. The
philosophy of palliative care is to improve the quality of life of patients in chronic pain, and
those with life-limiting illnesses (O'Brien and Kane, 2014). Palliative care is given to patients
seeking to extend their life whereas the end of life care such as hospice is given to patients with
the intention of alleviating their suffering, as they approach their death (May et al., 2015).
Palliative care is also important in helping the patient’s kin cope with the knowledge of the pain
of their loved one. In the case of Michelle, Peter, her husband is aware that the triple negative
breast cancer that Michelle has is terminal (media.pcc4u.org). A palliative caregiver has to help
Peter accept that his wife will die, and help him go through the pain. This paper will give an

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analysis of palliative, chronic and end of life care using Gibbs reflective cycle (Husebø, O’Regan
and Neste)
Principles that govern the care of patients
The principles include the principles of autonomy, beneficence, non-maleficence, and justice.
The principle of autonomy involves the self-governance by the patient. It means that patients
have a prerogative to information concerning their medication and choose a treatment method
that they deem suitable (Rahmani, Ghahramanian, and Alahbakhshian, 2010). During caregiving,
nurses can access a lot of a patient's personal information. Nurses have the responsibility of
respecting the patient's private matters and only focus on ensuring the patient's comfort. If a
patient opts not to take a medication that is beneficial to them, the nurse must respect that
decision. In Michelle’s case, nurses have to provide information of all the medication she will be
taking and all the pain relieving procedures she will be subjected to.
The principle of beneficence is concerned with minimizing potential harm and maximizing the
benefits of medical care to a patient (Haddad and Geiger, 2019). The caregivers must, therefore,
avoid maltreatment of patients and help them in doing activities that the patients re unable to
carry out on their own.
The principle of non-maleficence protects the patient from harm, intentional or otherwise. It,
however, put the nurse in a morally compromising situation if the patient refuses to take
medication that can save their lives. Finally, the principle of justice ensures that a patient is
treated fairly and equally. For instance, a patient in the rural setting has the right to access
medical facilities available to a patient in urban areas. Palliative and end-of-life caregivers must,
therefore, incorporate all these principles in the treatment of their patients (Myburgh et
al., 2016).

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Feelings and Evaluation
Pharmacological and evidence-based complementary therapy
Pain is pervasive and can be physical, emotional, and even spiritual. Physical pain is broadly
classified into nociceptive and neuropathic pains (Clark, 2015; Newton, 2018). Nociceptive pain
occurs as a result of damage to the body. The damage is captured by nociceptors, which send
nerve impulses to the brain that recognize it as pain. On the other hand, neuropathic pain is
caused by injury to the nervous system. Unlike nociceptive pain, neuropathic pain does not occur
in response to external stimuli, for instance, phantom limb pain, which is experienced by
amputated patients even in the absence of aching. Emotional suffering is usually in the form of
fear, anger, and depression. The imminent knowledge of chronic pain and death triggers fear of
what follows in the patient. On discovering that she has breast cancer, Michelle’s heart breaks.
She feels hopeless, and helpless (“…my whole world turned upside down.”) (media.pcc4u.org).
Anger is caused by the thought of being unfairly treated by the universe. Patients with life-
limiting illnesses become angry because they can no longer live as before, and the anger may be
directed at the caregivers, healthy people, and even oneself. Failure to treat fear and anger results
in depression, which accelerates the rate of deterioration of the patient. Physicians must
understand the kind of suffering being experienced by patients with life-limiting illnesses, to
better know how to handle it and care for them.
It is crucial for the caregiver to understand the feelings of the patient in order to care for them
adequately. It is however; very difficult to know how someone in pain is feeling emotionally. To
get to know how a patient is doing involves having a conversation with them. Such discussions,
for instance, the end of life discussion, are difficult to initiate because they revolve around death,
and are usually with someone who knows that they are dying (Maciejewski, and Prigerson,

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2013). Getting to understand a patient's feelings is a very sensitive part of pain control in patients
with a terminal illness, and thus in many cases, it is usually avoided. Physicians are nevertheless
expected to know the emotional state of the patients, which will help them understand how to
ensure the patients' comfort. While remaining emotionally neutral and being sensitive at the same
time, the physician should ask the patient questions concerning their (patient's) perception of life
prior to being diagnosed and afterward. Questions such as, "what did you feel during the
diagnosis? ", and "how did you handle the news of your condition? ", will enable the caregiver to
understand the illness from the patient's point of view, and therefore maximize the care to be
given. Talking about the emotions of the patient is also therapeutic in that, it relieves the patient
of feelings of fear and anger, which may otherwise result in depression. Furthermore, talking
with the patient will psychologically help them accept their illness, and prepare them for what
will follow. The conversation is also a way of creating a rapport between the caregiver and the
patient. A good relationship between the patient and the physician makes the work of the
physician less frustrating and thus can effectively care for the patient.
The quality of life lived is more preferred by people compared to the quantity of life. It is why a
patient in excruciating pain will choose an early death, over the prospect of extending their life,
especially if the illness is terminal (Singh and Chaturvedi, 2015). Over the years, medical care
has leaned more on extending the life of a patient than its quality. The radiotherapies, surgeries,
chemotherapies, etc. have all been focused on eliminating cancerous cells in cancer patients, and
thereby overlooking the suffering brought by these treatments on the patient. The effects of
chemotherapy, for instance, are more debilitating as compared to the cancer itself, since the
medications target fast growing cells, bone marrow cells included.

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Research has shown that no level of technological advancement in medicine so far can
completely eliminate the pain experienced by cancer patients. However, to make life more
bearable even when death is inevitable, cancer patients and their physicians have opted for
complementary and alternative medicine (CAM), in addition to pharmacological medications.
Mills, Torrance, and Smith, (2016), state that a higher percentage (over 70%), of patients with
chronic pain, have benefited from CAM. Complementary medications mostly used in to relieve
chronic pain include homeopathy, acupuncture, chiropractic, osteopathy, herbalism, and on rare
occasions, aromatherapy and hypnosis.
Acupuncture
Acupuncture a component of traditional Chinese medicine, has been extensively applied in
alleviating chronic pain. It involves the use of needles to stimulate some particular points on the
body. The stimulation helps suppress cancer pain by causing pain (Gate Control Theory). The
effectiveness of this method has been shown; for example, it has helped in reducing vomiting in
patients undergoing chemotherapy. It has also been shown to relieve pain and stiffness, flashes in
women with breast cancer and men with prostate cancer and xerostomia.
Hypnotherapy
Hypnosis involves the patient in a dazed state to make them relaxed and prone to suggestion.
Research has shown that hypnotized people do not lose control of their mind, and therefore what
they say or do is what they will typically say or do while conscious. Hypnotherapy has been
shown to bring about pain relief in more than 75% of cancer patients (Singh and Chaturvedi,
2015). Research has also shown that hypnosis alleviates the fear, worry, and anxiety associated
with a cancer diagnosis, and therefore helps in bringing about the acceptance of one's condition.
Furthermore, research shows that hypnosis is able to alleviate anticipatory nausea and vomiting,

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which tend to occur before chemotherapy, especially if previous exposure to chemotherapy has
already caused nausea and vomiting. Hypnosis has also shown positive effects of improving
cancer patients' fatigue and hot flashes. It can, therefore, be used to relieve patients in palliative
and end of life care of their pain.
Aromatherapy
Aromatherapy involves the use of the extract from certain plants to lessen pain. That elixir is
either added to bathwater, used in massage or inhaled with steam. Aroma therapists have
recommended the use of oils from plants such as Syzigium aromaticum (clove), Cupressus
sempervirens (cypress) and Pelargonium graveolens (geranium). Lavender and citrus oils of a
good quality are also useful for relieving stress. Aromatherapy has been shown to cause short
term benefits on depression, anxiety, improved sleep and better pain control among cancer
patients, and thus improve their wellbeing.
Reflexology, Tai chi and Yoga.
The other CAM method used to lessen end of life pain is reflexology. The pressure is applied to
specific points on the body, which brings helps to relieve stress and cause physiological changes
that reduce the recognition of pain. Tai chi and yoga are also thought to cause pain relief in
patients with life limiting illnesses. The poses and stretches bring about the wellness of the mind
spirit, and body, which help in reducing the severity of chemotherapy and other cancer treatment
medications.
Mental health considerations
The excessive pain and knowledge of imminent death can be traumatizing to a patient in
palliative and end of life care. As a nurse in charge of their wellbeing, ensuring that they are
psychologically well is of utmost importance. Agonizing situations can affect a patient's mental

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health negatively, which results in mental conditions such as post traumatic disorder and
depression. Mental disorders exacerbate the illness. Feelings of exhaustion, hopelessness,
anxiety, sadness, and a general lack of interest in life are usually associated with depression
(Woo, Maytal, and Stern, 2006). Such emotions interfere with pain treatment since the patient is
usually resigned to their suffering. Furthermore, depression may result in bipolar disorder, a
condition that is characterized by extreme shifts in mood episodes. Bipolar disorder and other
such conditions aggravate their pain by making it hard for caregivers to optimally caring for the
patients.
The concept of total pain is used when diagnosing and assessing a patient's pain. Rome,
Luminais, and Blais, (2011), define total pain as encompassing physical, psychological, social,
and spiritual suffering. When taking care of a patient in chronic pain, the caregiver must take into
account the effects of the pain to the mental status of the patient. In addition, a caregiver must
consider that the consequences of pain such as anxiety may show symptoms that resemble those
of other mental illnesses, and therefore care must be taken not to administer the wrong
medication. Some conventional medicines for pain treatment can also adversely affect the mental
state of the patient. Benzodiazepines, for example, have aftereffects which include impairment of
coordination, addiction, and reduced memory (Substance abuse and mental health service
administration, 2012). Opioids also have adverse effects on the patient, such as addiction, opioid-
induced hyperalgesia, and serotonin syndrome due to drug-drug interactions. A caregiver must,
therefore, understand all the factors and their effect on the mental wellbeing during palliative and
end-of-life care.

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Ethical and Legal issues in advanced care planning.
Sudore et al., (2017), define advanced care planning as a process that enables patients to make
their own medical decisions, at a time when they are too debilitated to do so. They further state
that Advanced care planning (ACP) is geared to ensuring that patients receive medical care that
is in line with their principles, objectives, and preferences (Sudore et al., 2017).
Both the statute and common laws in Australia and the world as a whole, have guidelines that
ensure patients are adequately cared for, even when they cannot make the decisions. The law
mandates that a patient decide how they want to be cared for. It provides for the appointment of a
substitute decision-maker (a person who makes medical decisions for the patient when the
patient cannot do so), by the patients themselves (Austin Health, 2018). The law further States
that for an "unbefriended" patient, the substitute decision-maker should be provided by the state,
or should be appointed by the guardianship tribunal (Austin Health, 2018, Moye et al., 2017,
Jennifer et al., 2017).
Analysis
Patients in pain relieving programs are there for pain relief, and pain relief is the sole purpose of
palliative and end-of-life care treatment. A caregiver must always put the comfort of the patient
before any other thing, their (caregiver’s) principles included. The CAM methods, when used
alongside conventional methods for pain management Such as administration of analgesic
medications, significantly reduce the lack of comfort and debilitating fatigue in patients
undergoing palliative and end of life pain management.

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Conclusion
Patient wellbeing holds precedence over any other engagement to a nurse. Palliative and end-of-
life caregivers must, therefore, ensure that the patient is as comfortable as possible. They should
make sure that the patient benefits from the care and minimize their suffering since that is the
sole purpose of palliative and end-of-life care.
Action Plan
Taking care of a patient in chronic pain is one very difficult task in a nurse’s carrier. It is
however fulfilling to a nurse to know that the job was done well. It is therefore imperative to
include complementary and alternative medicine in palliative and end-of-life care, to ensure the
patient is as comfortable as possible.

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