Palliative care is comfort care for an individual who is no longer in need or desires life saving care. Most palliative care is offered near the end of life. Palliative care often takes a more holistic approach where therapeutic touch, pain management and a higher degree of interpersonal communications occur between the nurse and patient and the nurse and family occur. Members of the health care team often approach the situation by working together to ensure that both patient and family are offered palliative intervention both on a schedule (with pain management care) and sometimes on demand responding to newly emerging needs for both medical and social intervention and information surrounding the comfort needs of the patient. Doctors are often called upon to respond to new orders associated with patient symptoms on a 24-hour period some examples would be ordering increases in pain medication depending on level of pain as it emerges, medical treatment for nausea, or the suppression of seizure activity much of this depending on the condition of the patient. Nursing staff is often asked to obtain or make provision for food and beverage needs of the patient and sometimes the family on an ongoing basis. Support nursing staff, such as unskilled nursing staff is often asked to intervene with increased demands for bed baths and linen changes to support a more therapeutic environment for the patient. Referrals to hospital clergy or patient centered spiritual advisors as well as social work and our counseling intervention when the nurse deems it necessary by her discretion and the nursing staff may also be asked to communicate with and seek visits from loved ones at certain points in the care process, when family or patient requests additional needs. The whole support staff of the hospital may be asked to curtail or increase environmental interventions such as cleaning the patient room or bringing in meals at times when family or the patient desires privacy and then fulfill those needs at a later time off schedule when it is more appropriate for the individual.
The patient's real and perceived needs are paramount to palliative care, they drive the schedule where there is one for the patient and there may be a heightened sense of need for both medical intervention as well as interpersonal communication regarding assurance of comfort both physically and emotionally. In the palliative care process with one family during a five day period there were several ad hoc interventions needed when the intensity of pain heightened following disease progression and when nausea heightened in the diseases process. The patient was near end stage of a long battle with colorectal cancer and the distention of the abdomen, increased nausea and vomiting coupled with decreased bowel movement and increased discomfort proved difficult for the staff to manage. The patient and family were offered continual intervention through prn medication as well as prompt attention to cleaning and redressing the patient. In the early part of the period the patient required frequent linen changes and emptying of the emesis and bath basin as well as two to three additional bed baths during each shift of care. The patient and family also required an on call directive made to the patient's doctor to increase pain medication as well as prescribe an injectable medication for nausea and vomiting and an increased use of both upon orders from the doctor over the first three days, and declining over the final 48 hours of patient care. In addition many housekeeping duties fell to unskilled nursing staff as frequent bed changes and room clean up and clearance was called for when requested by family and patient, while she was still able to respond to the nurses. In the time frame of the final days of the woman's life there was a clear sense that the patient had the express desire to return home and seek a hospice care referral. The rapid degeneration of the patient made this request an uncomfortable one for family as they were gravely concerned that setting up such care would be unduly stressful on the failing patient and that she would likely not benefit from it even though it was her desire. A bereavement councilor offered by the hospice program came to assist the patient, at the request of nursing staff to ally the family's concerns and assist in the development of a hospice diagnosis and referral for services. The counselor determined that the greatest barrier to the patient going home for her final weeks or days was the family's expressed fear and discomfort with the patient care and the unknowns of her failing condition. The bereavement councilor was able to ally many of their fears by explaining the hospice offering and that the hospice program was inclusive, meaning they would be able to provide the patient's home environment with everything the family and patient believed they would need, prior to her returning home. This would include a hospital bed delivery and set up in a comfortable and convenient location in the home, all supplies that would be needed and obtaining a 15 day supply of palliative medication for the patient. From this session the bereavement councilor an LSW from the hospice/home health division of the hospital was able to schedule and be present for a hospice intake interview with the hospice nurse leader who would start in motion a hospice admission, provision of unskilled nursing care in the home as well as all the supplies the patient would need for returning home. The hospital nursing staff as well as the onsite social worker were asked on several occasions as well as volunteering to aide the family in their understanding of how injectable medication was to be administered for the patient and on what schedule, colostomy care, bed bathing, and linen changes and positioning while the patient was bedbound prior to the patient going home and the social worker from the hospital also asked the nursing staff to sit with the family and to help ally their fears about the home care process. The nursing staff also sat with the family and patient on several occasions and discussed the physical dying process, supporting questions and providing answers. All of these interventions seriously aided the family in allying their fear regarding the dying process and allowed them the opportunity to express feelings in a situation where no judgment was present. Supporting the family in overcoming their fears helped them greatly to overcome their misgivings and guilt regarding fear that they would not be able to adequately care for their loved one and potentially then be unable to fulfill her wishes to go home.
I feel that my own skills at providing routine palliative care were greatly improved by the experience of caring for this patient. I became extremely efficient at responding to the patient and family with immediate interventions that both improved patient comfort and supported the bereavement process, as reestablishing comfort seemed to be the most emotionally supportive act the nursing staff and others could provide. I was personally a part of teaching the bed bound repositioning, linen change and bathing skills to the family and felt tremendously helpful in doing so. I think once the family realized that the care of the individual would be supported with skill at home they were much more willing to meet the patient's wishes and take her home for her last few days and weeks. In a hospital setting it is a rare and unique opportunity to practice skills associated with the bedbound patient as for the most part patients are relatively healthy and ambulatory, with a few exceptions. Having been a CNA for several years these skills were paramount and even though the patient was still ambulatory for most of her stay, helping her and her family understand how they could help when the patient's condition deteriorated, without having to painfully transfer her to another location to change linens and such was extremely comforting to them. The verbal skills associated with comfort care were also essential to the process for myself as well as other care staff as quiet tones are essential during frank and open communication as well as sensitivity to both joy and fear of others. Making sure that the family was offered the opportunity to reminisce and communicate issues of history and identity of the patient was also key to making the care as personal as possible and gave the staff frequent opportunities to personalize communication and care. Helping the patient maintain her privacy and allowing space for the family was also essential to the process of her care as the patient's dignity regarding the deterioration of her physical body was a serious concern she voiced to staff and approaching issues such as cleaning and peri-care with a positive and open air really helped everyone understand that most people go though this process as part of their physical deterioration and that it was both normal and essential to comfort to…