Addressing Unmet Needs and Wishes of Patients and Their Families

The interdisciplinary specialty of palliative and end-of-life care has made significant progress over the past decade, but serious barriers to its implementation remain. To overcome these barriers, clinicians are urged to learn more about palliative care through local and national presentations, online courses, and individual reading. Additionally, they should support the education and training of others involved in implementing palliative care on an institutional level and review new research findings to apply them to daily patient care.

PALLIATIVE CARE IN PATIENTS AT A STAGE OF ‘END OF LIFE’
1.0. Introduction
For people living with advanced, chronic ailment, neither counteractive action nor
cure is conventionally conceivable. Instead of a straightforward goal like survival,
which makes as well as a need for the greater part of life, individuals who are living
with deadly disease have complicated the treatment priorities. In this period of life,
care must serve numerous and complex objectives and is influenced by patient, care
giver and medicinal services framework components. Regardless of causes and
variables, the expression "dying" is an ordinary piece of life, passing is frequently
regarded as a disease. Thusly, many individuals pass on in clinics, alone and in pain
(Patrick et al., 2003). Palliative care concentrates principally on reckoning,
anticipating, diagnosing, and treating indications experienced by patients with a
genuine or life-undermining disease and helping patients and their families settle on
therapeutically vital choices. A definitive objective of palliative care is to enhance
personal satisfaction for both the patient and the family, paying little heed to finding.
Albeit palliative care, dissimilar to hospice mind, does not rely on upon visualization,
as the end of life methodologies, the part of palliative care escalates and aggressive
symptom management and psychosocial support (Yoong et al., 2013). Helping
patients and their families comprehend the way of ailment and anticipation is a
significant part of palliative care close to the end of life. Moreover, palliative care
experts help patients and their families to decide suitable therapeutic care and to
adjust the patient's care objectives with those of the medicinal services group (Rome
et al., 2011). At last, building up the requirement for a restorative intermediary,
propel mandates, and revival status is a basic piece of palliative care toward the end
of life. Medicinal services experts including doctor, attendant, diagnologist and
paramedical workforce require an in depth understanding on patient problems so
that they could pay attention towards care of patients. The care should be specific
especially in critical situations to save life of patients. Most healthcare professionals
at junior level and student level are lacking the aspects of palliative care. Hence, the
topic of palliative care was selected to describe the essential features from nursing
perceptive. The present paper describes the aspects of palliative care for patients in
emergency department.
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2.0. Search strategy
The available and popular sources were used to search for the evidences. The
sources, diverse online electronic resources including BNI (British Nursing Index),
CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (the
Excerpta Medica database), Pubmed, The DARE (Database of Abstracts of Reviews
of Effects), HTA (Health Technology Assessment Database) and NHS (Economic
Evaluation Database). In addition, the available textbooks, magazines and articles
from newspapers from library have been searched to find out the relevant literature
for end of life. The search was made for past 30 years to collect the relevant sources
and link the evidences to the current context. Adequate measures were made to
channel the quest for the pertinent sources. The keywords utilized for palliative care,
end of life, nursing care, patient behaviour etc. The outcome of the search for the
relevant sources has been depicted in subsequent sections.
3.0. Methodological aspects for palliative care
3.1. Evidence based patient assessment
The first imperative is to discover why the patient is in the emergency department
and to perform a fast appraisal of their palliative care needs. The physician from
emergency department can start objective directed appraisals and arrangements
that can keep away from undesirable medicines, unseemly asset use, and undue
enduring. An adequate co-ordination among the medicinal services experts is
expected to impart the visualization unmistakably from the "best" observation
(Rosenberg et al., 2013). The specialists need to give and portray the clinical
appraisal for any wrong solution and it is to be imparted to next level of wellbeing
work constrain. Sometimes it is not possible to discuss the poor prognosis of disease
at end stage of life to their families. Instead, the heath care experts can use words
wisely for instance, avoidance of negative statements that may make the patient feel
abandoned. The doctors cannot use the statements like “Do you want us to stop
aggressive care?” instead, can use the statement like “We are here to ensure that
you receive the treatment that is best for you and in line with your personal goals.”
Based on the need of patient concerning ailment seriousness, the specialist should
be offer a key arrangement of treatment that is in accordance with the patient's
desires. The nurse in charge for the care of patient should summarize the patient’s
goals as per their understand and in accordance with the doctor’s instructions to
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initiate the nursing plan. The nurse should also provide an encouragement to the
patient/surrogate to advocate for their wishes in terms of change of treatment plan if
the current one is not showing any prognosis.
3.2. Need based care
3.2.1. Dyspnoea
Patients at end stage of life, whose symptoms are going to be changed during
treatment due to dysfunction of physiological system. Therefore, the patients should
be monitored on regular basis for the measurement of vital signs and assessment of
prognosis. Therefore, symptom management in the emergency department is an
important part of nursing service. The patients at a stage of ‘end of life’ are generally
suffer from breathlessness. The discomfort in breathing is a subjective sensation
rather than a diagnosis and is very common among many patients with chronic
illness, including those with cancer, chronic obstructive pulmonary disease,
HIV/AIDS, congestive heart failure, stroke, amyotrophic lateral sclerosis (ALS), and
dementia (Policzer & Sobel, 2008). Occasionally, dyspnoea arise from anxiety. A
pulse oximeter reading alone is not an indicator of dyspnea; rather, careful
examination of the patient and appreciation of their distress via facial expression,
level of anxiety, ability to speak in full sentences and accessory muscle use can
assist in determining the level of discomfort. A normal oxygen saturation and lack of
accessory muscle use should not preclude treatment of the patient’s described
complaint. In such situation, the patient needs to be administered with appropriate
medication and supplementation of oxygen if required.
3.2.2. Pain management
Most patients admitted in emergency department with pain due to surgical
procedures in general and at the stage of end of life in particular may suffer from
pain. The pain medication regimen should be revisited in case of poor prognosis and
adjusted if required. Facility with titrating common narcotics will allow for adequate
control of this prevalent symptom. The repercussions of narcotic analgesics on body
physiology should be monitored as narcotic analgesics produce respiratory
depression (Stott & Pleuvry, 1991). A balance for the minimization of adverse events
and pain suppression is needed for the patients. A combination of narcotic and non-
narcotic analgesics is needed for better suppression of pain.
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3.2.3. Nausea and Vomiting
The common complaints of patients with multiple aetiologies in nausea and vomiting.
The probable cause for such symptom could be anxiety, vestibular, obstruction,
medications, infection or toxins (Policzer & Sobel, 2008). Therefore, the cause
should be identified and an appropriate treatment can be given. A thorough
understanding of patient history and diagnosis can support in the identification of
symptom.
4.0. Implications for clinical practice
How early to include palliative care being taken care of by patients who conceded in
emergency department. There exists substantial variability in survival at ‘end of life’
for the patients with diverse diseases however it depends on the type and severity of
disease. Provisional recommendations have been made to offer palliative care at the
diagnosis of metastatic disease or in patients who have a significant symptom
burden (Howie & Peppercorn, 2013). However for patients with advanced disease
encountering significant symptom burden from anxiety, depression and other forms
of distress, it is not clear that specialized involvement of a palliative care team or
physician is always needed or most effective compared with existing treatment
through psychosocial support programs. Characterizing the perfect time of palliative
care intercession is likely going to be to some degree ailment and even patient
particular. Identification of patients in whom symptom burden is high will require
careful evaluation by medical experts and is likely to maximize the benefits of
palliative care. Additionally, studies of interventions in other disorders such as
metastatic disease settings will be important to validate benefits of early intervention
in other settings, to clarify the components of palliative care that are required to
improve outcomes and determine whether the improvements.
It is an important step from care perceptive, for the establishment for the
delivery of early palliative care services for the patients. Still improvement in the care
is desired for the patient care based on evidences. Therefore, it is recommended
that medical experts should undergo for additional training to improve the skills so
that the communication can be improved across the departments. The management
of symptoms to be able to provide standard palliative treatments for their patients
(Quill and Abernethy, 2013). Additional training in discussion of realistic expectations
of continued aggressive care versus a transition of care to that focused on reduction
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of symptom burden may be what is most needed to improve patient outcomes.
However, whether this does lead to measurable differences in patient outcomes is
yet to be evaluated.
From the evidences, it can be understood that the patients with serious and
life-threatening illness and for their families needs an improvement. Untreated
physical symptoms, poor communication between providers and patients, and
treatment decisions in conflict with patient and family preferences characterizes the
current standard of healthcare for our sickest and most vulnerable patients. The field
of palliative care was developed in direct response to the unmet needs and wishes of
patients and their families and the accomplishments of this interdisciplinary specialty
over the past decade have been remarkable. Nonetheless, serious barriers to
palliative and end-of-life care implementation remain. Clinicians are urged to learn
more about palliative care in order to overcome some of these barriers. Clinicians
cannot practice what they do not know, and therefore attending local and national
presentations of palliative care to increase the knowledge base is an essential initial
step. This can occur through local presentations, national meetings, on-line courses,
and individual reading and exploration.
Next, clinicians should support the education and training of others-those
involved in implementation of palliative care on an institutional level, and those with
whom they work on a daily basis. Clinicians can review new research findings for
palliative and end-of-life care, and apply these findings to daily care of patients.
Continued efforts are needed to overcome the barriers to successful implementation
of palliative and end-of-life care for patients with diseases such as cancer.
5.0. Directions for the future
Additional research is needed to further comprehend the part of early palliative care
in different infections with diverse stages. Further studies utilizing different locations
including a more diversity of patient populaces to better see how tolerant attributes
influence the potential advantage of these services. Trials that control for patients’
exposure to attention from the intervention and that evaluate other specific
components of palliative care will better elucidate which portions of a palliative care
intervention might be most useful for patients. Furthermore, comparisons of similar
services by medical experts who have received additional palliative care training
compared with palliative care specialists will help to identify whether integration of
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these services by primary physician is as effective as management of consultation
by palliative care teams. Critical workforce issues loom on the horizon and research
is needed to help determine what specific services and what specific service
providers are needed to optimally and sustainably deliver palliative care in a scalable
manner that may benefit patients at a stage of end of life.
6.0. Conclusions
From the available evidences, it can be concluded that the early palliative care is
starting to gather. It is clear that early discussions regarding disease prognosis are a
crucial first step in helping patients to better understand their treatment choices and
goals of care. For many patients with advanced diseases such as cancer, it is likely
that early contribution of palliative care will enhance results, including personal
satisfaction, and conceivably survival.
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