Palliative care nursing

Communication: Communication best practices (e.g., teaching goals of care conversations/

BACKGROUND: Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer.The literature to date is limited by the imprecise use of the term palliative and subsequent variable designation of patients into evaluable groups. STUDY DESIGN: Between 2000 and 2007, 303 patients underwent a operation for gastric adenocarcinoma. Patients who received a noncurative (R1/R2) resection were identified. A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life. RESULTS: One hundred and ninety five of them (65%) received a noncurative gastric resection. The operation was palliative in 47% (92/195) and nonpalliative in 53% (103/195). Palliative no curative operations aimed preservation of tumor-engaged organ’s function, enhanced quality of patient’s life till dead, but not prolonged his life. No curative no palliative operations aimed cytoreductive effect by removing the organ engaged with primary tumor and improve the results of postoperative complex treatment and prolong the patient’s life. CONCLUSIONS: There are important differences among patients undergoing noncurative operations for gastric cancer. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent in patients receiving noncurative operations. Considerable variation in defining palliative care has complicated the understanding of the role of surgery in managing patients with advanced malignancies.(1) Surgeons commonly use the word palliative to describe a procedure performed in the presence of unresectable disease, a patient with limited survival, or as acknowledgment that a successful curative operation is not possible.(2) Such imprecise and incorrect characterizations of palliation have contributed to varied interpretations of surgical indications and outcomes. Palliative care has been defined by theWorld Health Organization as “the total active care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychologic, social, and spiritual problems is paramount. The goal of palliative care is the achievement of the best quality of life for patients and their families.”(3) Others have further classified surgical palliation to include the evaluation of extent of disease (to include surgical biopsy), control of local disease, control of discharge or hemorrhage, control of pain, reconstruction and rehabilitation, and treatment of procedure-related complications.(4) Although these broad definitions provide a global understanding of the scope of palliative care, they fail to clarify the subject of surgical palliation. For example, inclusion of patients undergoing a surgical biopsy with those undergoing a palliative resection produces such dissimilar groups that the evaluation of important factors such as surgical morbidity and mortality is severely limited. Even in patients with known metastatic disease, it is difficult to make valid comparisons between contrasting clinical scenarios such as elective flap coverage of a complex wound versus an emergency laparotomy for gastrointestinal bleeding. Because ideal palliative care requires an approach defined in terms of a patient’s individual needs and values, identical procedures may play dramatically different roles for each patient.(5) Surgical palliation of malignancy is defined best as a procedure used with the primary intention of improving quality of life or relieving symptoms caused by an advanced malignancy.(1, 2, 5) Palliation is not the opposite of cure. Each term has its own distinct indications and goals and should be evaluated independently. Important considerations relate to the medical condition and performance status of the patient, the extent and prognosis of the cancer, the potential for a curative procedure, knowledge of the natural history of the primary and secondary symptoms, potential durability of the intervention, and the expectancy and quality of life of the patient.(6) By stressing quality of life and symptom control as key elements of palliative care, this definition not only maintains a primary focus on an individualized approach for palliative surgery but also is consistent with the recommendations from the World Health Organization definition, the landmark Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment trial,(7) and the American College of Surgeons Statement on Principles Guiding Care at the End of Life.[8] A survey of The Society of Surgical Oncology members demonstrated a need for clarity in defining palliative surgery. These surgeons strongly acknowledged the importance of quality of life and symptom control in evaluating the effectiveness of palliative surgery.(9)

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

Palliative care is “the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life (QOL) for patients and their families.”1 Therefore, if palliative care providers wish to evaluate the full impact of their care, they must measure changes in QOL as well as improvements in areas specifically targeted by particular interventions (e.g., pain; depression).

Background: A transitional care program was developed at a southern San Diego hospital to guide patients dealing with heart failure from an inpatient to an outpatient setting to decrease hospital readmissions. Although, very successful with a quarterly readmission average of 9%, patients that are considered end-stage heart failure categorized by ejection fraction less than 30% and have greater than one visit in a thirty day period do not qualify for transitional care. These patients’ readmission rates average 50%. The literature shows that patients who will not significantly improve within six months would benefit from palliative and hospice care, thus a palliative care referral process was created by the education director to better capture patients that fall into the advanced heart failure category. Evidence indicates that palliative care supports the best possible quality of life in patients and families facing serious illness. Purpose: The purpose of this evidence-based project is to utilize a palliative or hospice care referral process for end-stage heart failure patients that don’t meet transitional care criteria in an attempt to improve quality of life evidenced by QOLI questionnaire. Method: Members of the transitional and palliative care team will send a list of de-identified patients using only financial numbers via Microsoft outlook to the DNP student; he will then access the patient’s chart and ask if they are willing to participate in a two part questionnaire. A convenience sample of 10 patients with a primary or secondary heart failure diagnoses discharged from a suburban southern San Diego, California, hospital that did not meet transitional care criteria where presented with a Ferrans and Powers Quality of Life Index (QOLI) cardiac version. The first questionnaire will be presented during their hospitalization or within five days of discharge and the second will be presented at thirty days after discharge. Results: Utilizing the Ferrans and Powers Quality Index tool patients indicated a 19.25% increase in the perception of quality of life as well as an increase of 53.6% in their health and function score. Implications for Practice: The information gathered from this project can be utilized by physicians and nurse practitioners practicing at an inpatient hospital setting to help assess a patient’s needs, illness management, and quality of life related to heart failure. Utilizing the new referral process has potential to influence patient’s self-management, improve social support, and ultimately improve quality of life in patients with end-stage heart failure.

Public Awareness and Perceptions of Palliative and Comfort Care

Introduction and Aim: The goal of palliative care is to enhance the quality of life for patients and caregivers, focusing on symptom management for patients with conditions where treatment may not be possible. The burden of common symptoms in patients with incurable diseases is increasing, and traditional and complementary medicine (GETAT) practices are being used as a part of palliative care in many countries around the world. The aim of this study is to determine caregivers’ perceptions of traditional and complementary medicine practices and to investigate the factors influencing the demand for GETAT applications in palliative care, considering the conditions of the service. Methods: This cross-sectional, descriptive study’s population consists of caregivers of patients receiving treatment in a palliative care service conducted by family physician specialists. A mixed-method approach was utilized, employing face-to-face surveys with Likert-type questions and adding open-ended questions to the survey. Results: During the study period, 67 out of 72 caregivers who were providing care to patients were included. The average age of caregivers was 46.4 ± 13.7, and 55.2% (n=37) were female. As for education, 62.7% (n=42) had completed primary education. When inquired about GETAT knowledge, 56.7% had awareness, with the most common source of knowledge being acquaintances, neighbors, spouses, friends, and relatives at 31.3%, followed by social media at 16.4%. Among the participants who were knowledgeable about GETAT applications, the proportion of those who had previously applied it to a palliative care patient was determined to be 28.9% (n=11). Caregivers’ perspectives on GETAT applications included concerns about causing harm to the patient, individual patient-related factors, and inadequate or incorrect information about GETAT practices.When comparing GETAT knowledge based on gender, it was determined that women had a 24% higher awareness of the applications compared to men. In the group with lower education levels, the primary source of GETAT knowledge was found to be acquaintances, spouses, friends, and relatives (p&lt;0.05). When the caregivers’ knowledge levels of GETAT were compared with the diagnoses of the patients they were caring for, a statistically significant result could not be found. Conclusion: In our study, sociodemographic information and awareness of GETAT applications were found to be similar to the literature. In a study conducted in 2020 with cancer patients receiving palliative care, a usage rate of 30% for GETAT was identified, with herbal therapy being the most frequently applied method. In our study, even though our palliative care service included not only cancer patients but also all patient groups, the rate of GETAT application was found to be 28.9%. The low rate can be interpreted as stemming from the severity of the health conditions of palliative care patients. In Turkey, caregivers have concerns about GETAT applications in palliative care services. Although further research on the subject is needed, obtaining accurate information about GETAT applications from reliable sources can potentially change perspectives.

BACKGROUND AND OBJECTIVES:Twelve “good death” principles have been identified that apply to Westerners. This study aimed to review the TFHCOP good death perception to determine its validity for Muslim patients and health care providers, and to identify and describe other components of the Muslim good death perspective.SUBJECTS AND METHODS:Participants included 284 Muslims of both genders with different nationalities and careers. We used a 12-question questionnaire based on the 12 principles of the TFHCOP good death definition, followed by face-to-face interviews. We used descriptive statistics to analyze questionnaire responses. However, for new themes, we used a grounded theory approach with a “constant comparisons” method.RESULT:On average, each participant agreed on eight principles of the questionnaire. Dignity, privacy, spiritual and emotional support, access to hospice care, ability to issue advance directives, and to have time to say goodbye were the top priorities. Participants identified three main domains. The first domain was related to faith and belief. The second domain included some principles related to self-esteem and person>s image to friends and family. The third domain was related to satisfaction about family security after the death of the patient. Professional role distinctions were more pronounced than were gender or nationality differences.CONCLUSION:Several aspects of «good death,» as perceived by Western communities, are not recognized as being important by many Muslim patients and health care providers. Furthermore, our study introduced three novel components of good death in Muslim society.

Is There a Role for Herpes Zoster Vaccine in Chronic Pain Management?

United States: Overview of Cancer Pain and Palliative Care

Background: The morbidity and mortality of interstitial lung disease (ILD) is high, despite novel therapeutics. Recognizing unmet needs for symptom management, advance care planning (ACP), and support for people with ILD and their families, we developed a palliative care-ILD collaborative care pilot program to improve access to palliative care. Methods: In the quantitative arm of this mixed-methods study, we evaluated which patients were cared for through the palliative care co-management program and the impact of the program on rates of ACP and opioid prescribing. In the qualitative arm, we interviewed patients and family caregivers, as well as pulmonary and palliative care clinicians, to understand perceptions about palliative care. Results: Thirty-one patients were co-managed by the palliative care and ILD teams during the study period. Half (48.4%) had idiopathic pulmonary fibrosis. Mean forced vital capacity (FVC) was 61.7%. Nearly half (48.4%) received all of their palliative care via telehealth. With palliative care, the rate of ACP notes increased from 3.2% to 100% (p < 0.001), rate of advance directive completion increased from 22.6% to 35.5% (p = 0.046), and rate of physician orders for life-sustaining treatments (POLST) form completion increased from 0% to 35.5% (p = 0.001). Half (51.6%) were prescribed opiates, overwhelmingly short-acting opiates to use as needed for severe episodic dyspnea. Themes from the qualitative analyses included that the palliative care team was supportive and patient-centered, improved symptoms and medication side effects, and enhanced illness understanding. Clinicians reported how palliative care co-management improved patient care and clinician experience, but barriers to referral remain including misperceptions about palliative care on the part of providers and patients. Conclusions: Palliative care co-management for patients with moderately severe ILD holds promise, and our experience can inform groups at other centers who are interested in developing such care models. Ongoing challenges include systematically reaching all patients who are likely to benefit.

In Germany, palliative care has developed rapidly since the establishment of the first palliative care unit in 1983. More improvements in patient-centered care are only possible if legal requirements as well as education of physicians, nurses, and other professionals involved in palliative care are adapted to current needs. This paper provides an overview of legal and regulatory requirements including a critical appreciation of their influence on palliative care in Germany. Only recently has medical education in palliative medicine been implemented as an integral part of medical studies at German universities. Starting in 2014, physicians applying for a license to practice medicine will have to provide a certificate of basic training in this field. The challenge in upcoming years will be the establishment and enhancement of comprehensive, standardized, and quality-controlled education at the universities. Only six universities have established chairs for palliative medicine, and it will be essential to not only establish more chairs but also to involve medical students in the development of the education. Only minimal requirements are specified for education of nurses in palliative care in the legislation. However, standardized and quality-controlled advanced training courses are available. This training is frequently requested as a prerequisite for nurses working in palliative care. Only limited education programs exist for other professional groups that are an important part of the palliative care team. In addition to the development of palliative care for inpatients with an increasing number of palliative care units, hospices, and first chairs of palliative medicine, different forms of ambulant palliative care services have been developed. Changes in the legislation have influenced the situation for home care enormously in the last 5years, also making it more complex. With the Law for the Consolidation of the Competition in Compulsory Health Insurance ("Gesetz zur Stärkung des Wettbewerbs in der gesetzlichen Krankenversicherung"), a legal claim for palliative home care has been implemented in the fifth book of the social law in 2007. The ambitious goal of full coverage with comprehensive palliative home care has still not been achieved in most locations. However, after initial negotiation difficulties between palliative care providers and health insurance funds, an increasing number of contracts have been made. As a consequence-in addition to more than 240 palliative care units in Germany-more than one hundred palliative care teams have begun work in the field of specialized palliative home care. Legal regulations for the supply of opioids and other medications for the treatment of patients at home have been adapted recently, thus, facilitating fast and comprehensive medical treatment in emergency situations. Overall, the legislation has been adapted significantly, hence, contributing to improvements for patients requiring palliative care. It remains to be seen whether additional adjustments are required in the future.

Cancer and palliative care in Africa.

In research on co-creation in nursing, a caring manner can be used to create opportunities whereby the patient's quality of life can be increased in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. To promote quality of life, nurses must be sensitive to patients' and their relatives' needs in care encounters. Co-creation can be defined as the joint creation of vital goals for patients through the process of shared knowledge between nurses, patients and their relatives. The aim of this study was to explore nurses' experiences of caring encounters and co-creation in palliative home care from an ethical perspective. A hermeneutical approach was used. The material consisted of texts from interviews with 12 nurses in a home care context. The method was inspired by thematic analysis. Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. An overall theme, a main theme and four sub-themes emerged. Through ethical sensitivity and perceptivity, nurses can balance their actions in the moment and change their nursing care actions according to the patient's wishes through co-creation in encounters. Here the time is crucial, as the time needed is unique to each patient. The themes together can be considered prerequisites for good palliative home care. If nurses fail to be sensitive and perceptive in encounters with dying patients, good palliative home care cannot be achieved. Ethical sensitivity and perceptiveness can also be considered a part of nurses' ethical competence. Patients' dignity can be preserved through ethical sensitivity and perceptiveness, which is fundamental for good palliative care. Co-creation from patients' perspectives should be the focus of future research.

To explore how community nurses experience the collaboration with general practitioners and specialist palliative home care team nurses in palliative home care and the perceived factors influencing this collaboration. The complexity of, and the demand for, palliative home care is increasing. Primary palliative care is provided by community nurses and general practitioners, often in collaboration with palliative home care team nurses. Although these professionals may each individually be part of a fixed team, a new temporary team is often composed for every new palliative patient. These membership changes, referred to as team membership fluidity, challenge professionals to work effectively. A qualitative research design, using semi-structured interviews with community nurses. Participant selection happened through regional palliative care networks in Belgium. The network's palliative home care team nurses selected community nurses with whom they recently collaborated. Twenty interviews were conducted. A constant comparative analysis approach was used. Consolidated criteria for reporting qualitative research guidelines were followed. Formal interprofessional team meetings were not common practice. The other's approachability and knowing each other positively influenced the collaboration. Time constraints, the general practitioners' lack of expertise, communication style, hierarchy perception and income dependency negatively influenced the collaboration with general practitioners and determined palliative home care team nurses' involvement. The coping strategies of community nurses balanced between a behaviour focused to the patient and to the professional relationship. Specialist palliative home care team nurses were relied upon for their expertise but also to mediate when community nurses disagreed with general practitioners. Community nurses showed to be highly adaptable within the fluid team. Strikingly, dynamics described in the doctor-nurse game 50years ago are still present today and affect the interprofessional communication. Interprofessional education interventions can contribute to improved interprofessional collaboration. The study findings uncovered critical knowledge gaps in interprofessional collaboration in palliative home care. Insights are relevant for and related to professional well-being and workplace learning.