Principles of Palliative Care PDF

COURSE TITLE: PRINCIPLES OF PALLIATIVE CARE

INTRODUCTION
This assignment will be evaluating the outcome of the holistic assessment given to a patient
on frailty older adult hospital setting, taking into consideration the bio-psychosocial needs of the
patient. The impact of government policies and initiatives in the development of palliative care
services will be explained. The palliative and end of life care would be defined, its relevance to my
clinical area will be discussed. A brief account of my clinical case study will be given. The strategies
utilized in the assessment process from a bio-psychosocial perspective will be analyzed. The impact
of the holistic assessment process on the care planning process will be discussed taking into
consideration what would have happened if the assessment had not taken place and how the
assessment interrelate. The ethical issues arising in the implementation of care plans will be
discussed.
RATIONAL FOR PALLIATIVE AND END OF LIFE CARE.
In the year of 1900, ways in which people died in their own home has labelled death as a
taboo instead of a natural existence of life (Leadership Alliance, 2014). Therefore, delivery of care in
last few days of life was supported by the use of Liverpool Care pathways (LCP) (Department Health,
(DOH) 2013). However, an Independent review made by LCP, 'More Care, Less Pathway' (DOH,
2013) has found that strategy was not adequately supporting care and it did not given right services
to vulnerable and found great variation in quality and practice across both acute and community
settings. Thus, it was recommended that the LCP should be phased out and replaced with
individualized end of life care plans to aid an improved symptoms management. With the help of
this, patients who were in need of palliative and end of life care could get right services.
At this juncture, it is paramount to define palliative and End of life care. Palliative care is an
approach that improves the quality of life of patients and their families facing problems that were
connected to life-threatening illness, through prevention and relief of suffering by means of early
identification. On the other hand, impeccable assessment and treatment of pain and other problems
related to physical, psychosocial and spiritual (WHO, 2002). While, end of life care is the aid which
basically helps all those with advanced, progressive, incurable illness to live as well as possible till the
moment they die ( National End of Life Care Strategy, 2008).
THE CASE STUDY
I work in an elderly frailty post acute ward. Mrs. Jane, aged 85 years for confidentially
purpose will be used for the present case (Nursing and Midwifery Council, (NMC), 2015). She got

admitted in the hospital due to falls treatment given for urinary tract infection (UTI) secondary to
dehydration. As given by NICE, (2004), over 230,000 people in England and Wales gets cancer each
year, and this chronic disease could be considered as one quartered reason of all deaths (NICE,
2004). In addition to being frail, Mrs Jane, has been recently diagnosed of advanced, progressive
cervical cancer, with choice of no further treatment (The General Medical Council, (2010) and Gold
standard Framework, 2011). Therefore, she was identified as nearing the end of life. After some
time, she was referred to the palliative team who advised the nurses to complete an individualised
care plan. Other co-morbidities are osteoporosis, hypothyroidism, poor appetite, recurrent UTI and
right hip replacement. She has been bed-bound due to complaints of lower back and left with hip
pain as well. Away with this, an X-ray was performed to rule out a fracture. It was discovered that
Mrs. Jane has severe compression to her spine. She used to have 5mg of morphine sulphate tablets
twice daily prior to admission. Mrs. Jane is psychologically distressed as she have the fear of inability
to walk again or go back to her sheltered accommodation where she had lived more than 5 years.
PHYSICAL ASSESSMENT
On getting to Mrs. Jane, I introduced myself, drew the curtain for privacy, explained to her
what I intend to do and asked her if it is fine and she accepted and understood perfectly. In present
case, Mrs. Jane has been immobile due to pain and investigation revealed severe spinal cord
compression (SCC). On the given point of view of Ropper and et. al., (2017), complications from
spinal cord injury will depend on the site of compression and severity of associated neurological
dysfunction. Paniagua-Collado and Omar (2018) mentioned that, SCC is being considered as complex
and challenging condition that greatly affects the quality of life. Also, pressure ulcer is a cause of pain
and physical debilitation and patient in a supine or semi-recumbent because of immobility are more
at risk (NICE, 2014). Considering the fact that Mrs Jane has been bedbound and barely move in bed,
has been identified that Mrs Jane will be at risk of pressure ulceration.
As mentioned by NICE, (2001), identifies the use of Waterlow Pressure damage scale in
conjunction with clinical judgement to determine the risk of developing pressure ulcer in an adult.
The Waterlow scale is divided into different segments; the skin assessment, age, gender, nutritional
status, medication and neurological deficit. There are several specific risk factors that place patients
at increased risk of pressure ulceration (Rajpaul and Acton, 2016). Also, Davies (2018) added that
considerations must be given to other conditions like dehydration, urinary and faecal incontinence.
In addition, NICE, (2014) points out that patients at risk of pressure ulcer will have multiple risk
factors. Some of the risk factors observed and that will put Mrs Jane at risk of pressure damage are;

redness to her heels and sacral areas, poor nutrition, on immuno-suppresant drug, female is
accorded higher score than male, she is doubly incontinent, frail and advanced in age.
How my biological assessment informed my patient care
Dougherty and Lister (2015) express that pressure ulcer occurred due to unrelieved pressure
or pressure with shear or friction and it is more common in patients above 65 years of age. Pain or
discomfort at a potential pressure ulcer site may be a precursor to pressure damage and could be
considered as a risk factor (Davies, 2018). Also, Tidy (2017) recommend that a careful and frequent
turning of the patient is essential. Hence, care plan was designed to assess pain regularly and to
change the position of Mrs Jane's body every 2 hourly in bed. The National Pressure Ulcer Advisory
Panel (NPUAP) ( 2014) recommends the use of specially designed mattresses to help reduce the risk
of pressure ulceration. Mrs. Jane was put on pressure relieving mattress and prevalon boots was
applied to each foot to offload the heels. NPUAP et al also advised to consider the use of slide
sheets when repositioning at risk patient to reduce the risk of shear and frictions. She was
repositioned adopting the appropriate manual handling technique. she was encouraged and
supported to sit out daily, chair cushion was also ordered for her sit on. Plan was also implemented
to improve her nutritional status, she was put on food chart and was encouraged with snacks in
between meals. Though, Mrs Jane on assessment was at high risk of developing pressure ulcer was
able to go home with her skin intact.
Psychological Assessment
As given by De Souza and Pettifer (2013), pain as one of the most prevalence symptoms
experienced by cancer patients. Rosser and Walsh (2014) view pain as the primary symptoms of
spinal cord compression. One of the complications of spinal cord compression is depression
associated with restriction of activities of daily living due to immobility (NICE, 2008). The psychology
distress expressed by Mrs Jane was that of institutionalisation due to immobility caused by severe
lower back and hip pain. Therefore, my psychological assessment of Mrs Jane would be focusing on
pain management.
It has been argued that nurses have a pivotal role in undertaking pain assessment ( the
chronic Pain Policy Coalition (2007). Mrs Jane's pain was assessed using the numerical rating scale
which helped her to express the intensity of her pain on a scale of 0-10. 0 being no pain, 1-3 being
mild pain, 4-6 being moderate pain and 7-10 severe pain (Moller, (2012) and Parson and Preece,

(2010). Mrs Jane would always rate her pain as being severe, even though she appeared drowsy
most of the time but, would scream at the slightest touch and grimace her face when approached
for any nursing intervention. Bullock, Clark and Rycroft-Malone (2012) made understand that one of
the principles of a good assessment is to be non-judgemental. Opioid analgesia are the standard of
care for treating moderate to severe pain in patients with advance illness (Satija,2014). Therefore,
breakthrough analgesia of oral morphine was administered regularly rather than as required every
4hourly. The International Association for the study of Pain (IASP, 2017) advised healthcare
professional to see pain beyond physical problem. Therefore, Mrs Jane was assessed by the doctor
and the palliative nurse and she was prescribed amitriptyline and gabapentin in addition to the
butrans patch and breakthrough oral morphine.
Bullock, Clark and Rycroft-Malone, (2012) express that pain is a subjective experience and in
persistent pain, a uni-dimensional pain scale may be used and that continued monitoring is vital in
confirming the effectiveness of the intervention. Also, performing regular assessment, responding
to physical or emotional changes, and adjusting treatments and care accordingly are therefore vital
elements of the nursing care plan (Bullock, Clark and Rycroft-Malone, 2012). Therefore pain was
assessed regularly and Mrs Jane's pain was controlled by taking into consideration the
multidimensional aspect of pain. Mrs Jane's pain was monitored randomly especially before change
in position or when about to be seen by the physiotherapist, ensuring appropriate documentation to
monitor the effectiveness of the clinical intervention. However, she remain bedbound and off her
baseline due to frailty and general health decline.
SOCIAL ASSESSMENT
In this section would be discussing my role in discharging Mrs Jane to her preferred place of
resident and the support given to her daughter. Sheppered et al (2013) stressed that effective
discharge planning reduces chance of unplanned readmission to hospital and improve the
coordination of services following discharge from the hospital. Bowen, (2014) stated that home care
can reduce symptom burden as well as making patients more likely to die at home. Considering the
nursing care, Mrs Jane has been receiving on the ward, the management of pain, the pressure areas
care, the impact of urinary incontinence could have on Mrs Jane and because her condition could
change was referred to the district nurses for supports and other charitable organization for
assistance with some activities of daily living. DOH (2003a and 2008b) express that effective
discharge is dependent on partnership with the patient and their carer. Also, World Health
Organization (2002) demands a support that help patients to live as actively as possible until death.
Therefore, the plan to refer Mrs Jane to the district nurses and other support workers in the

community was discussed with Mrs Jane and her daughter to ensure consent and to avoid bias at
the point of contact.
In the process of the assessment, an ethical dilemma surfaced as Mrs Jane's daughter, a
single mother to a boy of 7years of age, as well as working 9am to 5pm Monday to Friday, raised a
concern that the pressure would be too much for her checking on her mother's welfare every day,
as well as unexpected occurrence at night. Hence, contrary to her mother's opinion, she suggested
that her mother should be discharged to a residential home or to where she is living. However, Mrs
Jane had clearly express that it would be too stressful for her at this point in life to be discharged to
an unfamiliar environment and would rather be given all the support she required to live until death.
NICE, (2004) states that patient has the right to be respected. Hence, the daughter's suggestion for
her mother to be discharged to other destination was averted after much consideration within the
multi-disciplinary team as Mrs Jane has capacity to make decisions for herself.
HOW MY SOCIAL ASSESSMENT INFORMED MY PATIENT CARE
In this section, it will be discussing that the impact of social assessment on Mrs Jane. One of
the contributory factors of Mrs Jane's low mood was fear of being institutionalized. Also, discharging
a patient to an unfamiliar environment might lead to social isolation, low mood, depression, even
worse pain than reported and low quality of life (Kisane and Zaider, 2010 & Lees, 2013). NICE,
(2004), state that patient should be supported to preserve their social networks, attend to personal
care, cleaning and shopping. In other way to facilitate her desire to be discharged home worked
with the palliative team, the social worker and the doctors to fast track her discharge home.
Furthermore, based on my assessment and that of the occupational therapist has been able to
support Mrs Jane through, appropriate referral to the community team in order to meet her needs
at home along with providing the relieve from burdens on her daughter. Poor care co-ordination
between sectors has repeatedly been viewed as a problem in studies of patients' experience (NICE,
2004). Other team involved in her care which is a palliative team who referred her to the community
palliative team on discharge and the doctor who was responsible for updating the general practice
on discharge from the hospital.
A critique of the holistic assessment

Alfaro-Lefevre (2014) states that assessment should incorporate the holistic dimensions and
be explored with the person being assessed. NICE (2009) made understand that patient with
physical health problem are at greater risk of depression. Pain has been identified as the root of Mrs
Jane's psychosocial problem. She was identified as at risk of pressure ulcer due to reduced mobility
as a result of pain that leading to depression as her fear being institutionalized and inability to be
discharged home.
The New NHS: modern social and dependable (DH, 2003b) demands to achieve a person
centred and quality of care requires a good partnership among the multidisciplinary team. Also, the
Cancer Link (2000) and Commission for Health Improvement (2001), revealed that the patients
intent to be treated as an individual, with dignity as well as respect. Therefore while the doctors
addressed her psychological needs medically, I treated Mrs Jane and her daughter with dignity and
respect. They were listened to, shown her compassion, involved her in every process of her
assessments, ensuring adequate information to ensure consent in the delivery of her care planning
and decision making process. Moreover, it was well supported in her choice to spend the rest of
days in life at home. Mrs Jane's needs was attended to promptly, in particular was the
administration of breakthrough analgesia as soon as possible. DOH, (2008) points out that as death
approaches, the symptom burden of a patient may worsen and require more aggressive palliation.
Though Mrs Jane was referred to the palliative and district nurses for support in the community.
Since, the pain is a subjective experience (McCaffery, 1968), the concern is how soon same need
would be responded in the community with the shortfall in the numbers of outreach or community
nurses reported by the House of Common (2015).
Optimal pain relief will not be possible unless all the elements of total pain are addressed
(WHO,2002). Biologically, Mrs Jane's pain was assessed using the NRS. It is simple to use and
recommend for preferring in context of older people (Hindle and Coates, 2011). The NRS enabled an
appropriate level of intervention according to the WHO pain ladder. Though, Satija, (2014) states
that pain management for cancer patients requires critical pain assessment and thorough patient
evaluation including psychological assessment. However, Bullock, Clark and Rycroft-Malone (2012)
expressed that a strategy that involves the use of a multi-dimensional pain assessment tool,
including the use of open ended questions should be used to enable nurses for capturing many
aspects of this symptom. As Mrs Jane was drowsy most of the time, is unlikely that a comprehensive
pain assessment would be more suitable.

NICE (2004) expressed that the patient's needs might go unrecognised by professionals, who
subsequently do not offer referrals. Also, caring for palliative patients involves a multidimensional
approach ( DOH, 2008 and Bowen, 2014). Therefore, necessary referrals were made to ensure
maximum support in the community. NICE (2004) points out that poor inter-professional
communication and co-ordination can lead to suboptimal care. Mrs Jane's assessment and care
planning was well documented on the electronic patient record and shared with the
multidisciplinary team at our ward daily board meeting. She was also reassured by giving her a
detailed information of all the supports to meet her needs on discharge.
CONCLUSION
The above report conclude that the impact of government policies in ensuring an improved
palliative care services have been explained. The impact of the holistic assessment process on care
planning have been discussed. The strategies utilized from a bio-psychosocial perspective have been
analysed.

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