Palliative care interventions for end-stage colorectal cancer patients

Palliative Care/Gibbs

DESCRIPTION

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.

FEELINGS

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.

ACTION PLAN

This experience was paramount to my role as a student nurse as I was made aware of countless sensitivities to patient interaction. The role a nurse plays in supporting transitions like end of life care is essential to establishing a good rapport with patients and family and essential to understanding the special needs of a patient who is no longer needing or seeking life saving care. Though much of hospital work surrounds supporting temporary health needs and needs that support recovery the process of palliative care is a more interpersonal and in a sense offers the patient and family, when approached correctly recovery in a much more emotional transitional way, with regard to emotions, fears and expectations of end of life processes. So in a sense the role of the staff is to approach the issues at the beginning and end of bereavement as if they are holistic aspects of emotional rather than physical recovery. To some degree it is also clear from this experience, with this family that offering comfort measures to the patient and the family is integral to individuals obtaining positive outcomes emotionally from a difficult transitional period. I also learned that offering supportive emotive responses to my own feelings of loss and empathy is acceptable and even helpful as long as it is responsive to the professionalism of the role and does not supersede or outweigh the feelings of the family. I also learned that the experience of grief in the professional setting is far more positive if such grief is associated with a personal connection with the patient and family and with regard for the individualism of the patient and family. In other words getting to know who the patient is did not challenge my ability to care for her professionally and in fact added a great deal to my ability to care for her with dignity and feeling. I will likely use this aspect of the palliative care learning process as often as possible with all patients as getting to know the individual, even just minimally really helped me respond to her needs, wishes and fear and to those of the family.