CHCPA301B Deliver care services using a palliative approach
Reading 1: Apply a palliative approach
Contents
Reading 1: Apply a palliative approach 3
Introduction 3
Differentiate between practices applicable in curative and palliative approaches 3
Apply the principles and aims of a palliative approach in caring for clients 4
Use an approach that reflects an understanding of the client’s needs as holistic and extending over time, not just end-of-life 6
Reading 1: Apply a palliative approach
Introduction
This reading will introduce you to the differences between what has been traditionally called ‘palliative care’ and the term ‘palliative approach’ used in aged care. As an aged care worker you will be working with people who are approaching the end of their lives due to age or disease process. Care of these people is not simply based on their physical needs, but also encompasses psychological, cultural, social and spiritual needs. As you read through this section, you will understand the holistic needs of the person at the end of his/her life and how these needs can be best met.
Differentiate between practices applicable in curative and palliative approaches
As you are no doubt aware, the number of people living to old age in Australia is increasing, as it is in other developed countries. The reasons usually given for this increase are better medical care, including improvements in technology, as well as an awareness of lifestyle factors which limit life such as smoking, lack of exercise and diet. Consequently, older people are likely to have complex medical conditions for a long period of time rather than acute illnesses which result in death. In addition to medical conditions, many older people are living with dementia, which can be progressively more disabling until death.
The term ‘palliative care’ has, in the past, been associated with the care of the person with a cancer. In recent years the term ‘palliative care’ has been broadened to include the care of not only people with cancer, but also those in the terminal phase of any illness, such as dementia, chronic obstructive pulmonary disease (COPD), multiple sclerosis (MS), cerebrovascular accident (CVA), and Parkinson’s disease.
The World Health Organisation (WHO) (2003) has defined ‘palliative care’ as:
An approach that improves the quality of life of individuals and their families associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical psychosocial and spiritual.
A ‘palliative approach’ is not simply confined to the final stages of an illness. Rather, a palliative approach acknowledges that the quality of life of a person with a life-limiting illness such as dementia can be maintained by early identification, assessment and treatment of pain, and by meeting the person’s physical, cultural, social, psychological and spiritual needs. A palliative approach is taken when an individual person is moving towards the end of his life and there is no reasonable likelihood of extending life by curative means.
A palliative approach incorporates a concern for the holistic needs for the client and their carers that is reflected in assessment and in the primary treatment of pain and physical, psychological, social and spiritual problems.
The focus of a ‘palliative approach’ is to provide comfort by the management of symptoms, by discussing death and dying openly with the individual (where possible) and his/her family, and knowing and following the person’s wishes. In an aged care facility, taking a palliative approach may include treating symptoms such as pain and anxiety, and following the person’s wishes to remain in the aged care facility until death rather than to die in a hospital. Many people in the community choose to remain in their homes for as long as possible when they are dying. Residents of an aged care facility regard the facility as their home and most wish to die there rather than a hospital.
Taking a palliative approach does not mean that no treatment is given for medical conditions eg it may still be appropriate for the person to take his/her medications for a heart condition, because by doing so, the person does not have chest pain.
Apply the principles and aims of a palliative approach in caring for clients
A palliative approach can be provided in the residential aged care facility or home as long as there are adequately skilled people who can give the care which is appropriate. The person can be made comfortable and symptoms managed without the distress of a transfer to hospital. In most instances, a multidisciplinary team can provide advice regarding care. A multidisciplinary team might consist of people drawn from a number of professions, such as:
· general practitioners
· nurses, including palliative care specialists
· carers
· specialist doctors eg oncologists, geriatricians
· pharmacists
· allied health professionals eg physiotherapists, dieticians, speech therapists, social workers
· pastoral care workers, ministers of religion.
In fact, due to the many aspects of palliative approach, a multidisciplinary team is best to meet the needs of the individual person. The aged care nurse is especially important at this time because he/she often spends a great deal of time undertaking the personal care needs of the person and can understand and communicate his/her needs when the client is unable to do so.
Taking a palliative approach throughout the person’s health decline, as in advanced dementia, has a role in providing advice and intervention in relation to:
· Pain management and management of other symptoms such as depression and anxiety.
· Management of issues relating to nutrition and hydration as the person may stop eating and drinking towards the end-of-life.
· Education of the client and the client’s family in relation to the disease process and ensuring that they are fully informed about the likely path that the disease will take.
· Support regarding advance care planning ie planning and documenting the client’s wishes for his/her end-of-life care.
· Support for increasing disability eg providing additional personal hygiene and toileting support from the care staff; enabling the client to use a wheelchair when no longer able to walk.
· Spiritual and psychological support for the client and his/her family as they proceed towards the end of the client’s life. This may simply be giving time and listening to them in an empathetic way.
· Prompt access to specialist palliative care services if required.
/ Reflection: Personally achieving a ‘good death’Consider that you are a person aged over 75 years with a disease that cannot be cured. Write a list of what are the most important issues for you in achieving a ‘good death’. Issues you might consider could be:
· being pain-free
· being able to move around freely
· resolving long-standing conflict
· finding your own spirituality
· satisfying final wishes eg saying good-bye to special people or places
· dying at home.
Feedback
There is no ‘correct’ answer for this activity. Every individual defines ‘good death’ in his/her own unique way. However, there are some elements of dying well that are common to most people, including being informed about the condition and having the ability to accept or reject care. A supportive environment that provides care consistent with cultural values, beliefs and practices, and ensures freedom for spiritual practices is also tremendously important for the person towards the end-of-life.
Use an approach that reflects an understanding of the client’s needs as holistic and extending over time, not just end-of-life
A palliative approach to care specifically aims to improve the quality of life for the client who has a life-limiting illness or who is dying due to ageing, by reducing the suffering through early identification, assessment and holistic treatment of pain, physical, social, psychological, cultural and spiritual needs. This means that treatment is not delayed until the end stages of an illness or the ageing process.
Case study
Martin, aged 79, is admitted to a residential aged care facility for end-stage renal (kidney) disease. He has been on dialysis for many years but recently his overall health has declined and his life is now limited to approximately six months. Martin has been separated from his family for 30 years due to an unpleasant divorce. He has never seen his grandchildren. Martin discloses that he would like to seek forgiveness from his family and see his grandchildren before he dies. Martin’s needs not only relate to pain and physical discomfort from his disease, but also he has social needs (to see his family), psychological (to accept his own death) and spiritual (to find meaning in his own life).
The example of Martin is only brief and underestimates the true intricacy of human life. However, if Martin’s needs are understood by aged care staff, appropriate care can be given. In Martin’s example, he would benefit from social work, pastoral care, and chaplaincy interventions as early as possible after his admission.
In the above example of Martin, contact with his family is important to him. Whether or not this can be realistically achieved is not important to Martin’s peace of mind. His need is to be supported emotionally throughout the rest of his life. As an aged care worker, you will be need to be equipped to support your client holistically – this can include accommodating their spiritual needs
Palliative approach
The palliative approach includes providing support for the family or other significant people during this process, and keeping everyone fully informed that a positive approach is being taken to provide symptom relief and comfort for the client. The palliative approach encompasses the needs of the client and his/her loved ones and carers as a whole unit, all of who have needs which must be addressed.
Underlying the philosophy of a palliative approach is a positive and open attitude towards death and dying. Traditionally, death and dying has been a taboo subject for many cultures. Having an open attitude which has been developed through your education about death and dying, and through reflections on your own experiences with death and dying, will enable you to provide care for the client without being afraid of the process of dying and withdrawing from it.
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© NSW DET 2009