Tuesday, December 4, 2007

Nurse's Role in Palliative Care

Research indicates that professional education and knowledge on end-of-life or palliative care has been limited or nonexistent in both nursing and medicine (LaPorte-Matzo & Sherman, 2001; Foley, 2005). Competent and compassionate end-of-life care is a responsibility of all health care professionals. Nurses consume the health care profession, and thus, have a tremendous potential to effect change in the care of the dying and their families.

(LaPorte, Matzo & Sherman, 2001). Armed with an understanding of the goals of palliative treatment,
nurses can play a leading role in palliative care by creating and implementing a plan of care.
The World Health Organization published its first definition of “palliative care” in 1986
and a revised version in 2002 (Foley, 2005). The revised definition the WHO provides states:
“Palliative care is an approach which improves quality of life of patientsand their families facing life-threatening illness, through the preventionand relief of suffering by means of early identification and impeccableassessment and treatment of pain and other problems, physical,psychosocial, and spiritual.”
By definition, palliative care now addresses the continuum of a patient’s illness and
preventing suffering rather than simply treating it (Foley, 2005). Caring for the whole person is
a key concept in palliative care (Seery, 2004). An easy way for nurses to accomplish this is by
considering the domains of holistic care, that is, the physical, psychological, social, and spiritual
needs of a patient.
Dying patients asked to rank their basic needs have said that they wished to be free of
pain, anxiety and shortness of breath; to be kept clean; and to be touched (Seery, 2004). For
many patients, the diagnosis of a chronic or terminal disease means the immediate end of a
“good life.” This is why palliative care today seeks to integrate curing with caring, to improve
quality of life and support the patient’s view of a “good death.” ( Rushton, Spencer & Johanson,
2004). The goals of palliative treatment are concrete: relief from suffering, treatment of pain
and other distressing symptoms, psychological and spiritual care, a support system to help the
individual live as actively as possible, and a support system to sustain the individual’s family
(Kuebler, Davis, & Moore, 2005).
Comfort measures should be included in the physical component of care which involve
frequent repositioning and padding of bony prominences (Seery, 2004). Attention should also
be taken to skin care to prevent the development of pressure ulcers. Additional physical
symptoms include nausea and fatigue. Nurses should focus care of the tired patient on
promoting adequate, restful, and restorative sleep when possible (Kuebler, Davis, & Moore,
2005). This can be done by preventing or reducing the factors that are disturbing the patient’s
sleep or that have the potential to do so and by providing bedtime routines, comfort measures
and a setting that accommodates sleep.
Palliative care can relieve most, but not all of terminal suffering for the patient. While
most experts agree that 95% of pain can be relieved by treatment that is acceptable to the
patient, the fact still remains that 5% of the palliative care population must cope with
unrelieved pain (Quill, 2001). The goals of palliative treatment become less concrete for these
patients. Nurses must acknowledge the fear for patients and families regarding unrelieved
pain. Also, it becomes paramount for the nurse to understand the therapeutic and institutional
barriers to effective pain management. The palliative care nurse may need to rely on non-
pharmacological alternatives to complement pain management (LaPorte, Matzo & Sherman,
Nurses can face an ethical dilemma when treating patient suffering. The most
commonly cited reason for requesting physician-assisted death is not pain, but rather
increasing weakness, debility, fatigue and dependence (Quill, 2001). Some end-of-life patients
experience terminal delirium and lose the capacity to make decisions for themselves toward
the end (Quill). This can lead to patient agitation and the decision to sedate such a patient who
can now no longer consent to such treatment. The palliative care nurse needs a plan for
handling such tough symptoms especially if they threaten the patient’s integrity during the
dying process. Inevitably, nurses may struggle with morally and ethically compromising
decisions such as these.
When addressing psychological, social and spiritual needs of the patient, an effective
way to determine his or her needs is to ask open-ended questions designed to elicit thoughts,
feelings, hopes and values. Utilizing therapeutic communication and empathy tends to not only
help the patient feel better, but also improves the patient and family’s perception of care
during the last days (Seery, 2004). Thus, care planning with the palliative patient should include
more than discussion of treatment preferences. Nurses should also address patient values,
beliefs, and goals. Patient values are the foundation for treatment preferences and medical
decision making (Kuebler, Davis, & Moore, 2005). Nurses can assess values and goals by asking
open-ended questions such as: What is most important to you as you think about the future
(Kuebler, Davis, & Moore, 2005)?
Nurses must also be aware that they bring their own spiritual and cultural beliefs and
values, as well as their own personal and professional experiences regarding death and dying to
palliative care nursing (LaPorte, Matzo & Sherman, 2001). Without this awareness and coming
to terms with it beforehand, the potential for biased care exists. This is why some professionals
have argued against using the method of open-ended questions during palliative care (Quill,
As nurses make every effort to ensure the psychological and spiritual component of
palliative care and help to create valuable support systems, they place themselves at risk of
becoming emotionally and physically drained (Laporte, Matzo, & Sherman, 2001). Nurses often
spend many hours in the supportive role and can suffer from caregiver strain. Efforts should be
made by the palliative care nurse to seek their own emotional outlets and plan care
Nursing’s history reveals compassionate care for the dying and that care exists beyond
cure. Presently, nurses must take the lead in integrating palliative care into the daily practice of
every nurse, making it a core competency for all nurses who care for people with actual or
potentially life-limiting illnesses (Rushton, Spencer & Johanson, 2004). In summary, nurses are
responsible for educating themselves on the goals of palliative treatment. With this
accomplished, nurses can most effectively create and implementa plan of care, thus becoming
the best advocate for the palliative care patient and their families.

Foley, K. M. (2005). The past and future of palliative care. The Hastings Center Report,
35, (6), 42-. Retrieved February 20, 2006 from ProQuest database.
Johanson, W; Rushton, C. H.; & Spencer, K. L. (2004). Bringing end-of-life care out of the
shadows. Nursing Management, 35, (3), 34-. Retrieved February 20, 2006 from Infotrac
Kuebler, K.K.; Davis, M.P.; & Moore, C.D. (2005). Palliative Practices: An Interdisciplinary
Approach. (63-396). Elsevier Mosby, Philadelphia, PA.

LaPorte-Matzo, M., Sherman, D. W. (2001). Palliative Care Nursing: Quality Care to the
End of Life. (xvii – 278). Springer Publishing Company, New York, NY.

Quill, T. (2001). Caring for Patients at the End of Life: Facing an Uncertain Future
Together. (115-154). Oxford, University Press.
Seery, D. H. (2003). Shifting gears: from cure to comfort: hundreds of thousands of
patients die in ICU’s each year, but few receive palliative care. Nurses play a central role in
transitioning from aggressive treatment to comfort care. RN, 67, (11), 52-. Retrieved February
20, 2006 from ProQuest database.

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