Role of a Palliative Care Nurse

Role of a tout ensembleeviatory disturbance hold upP every(prenominal)iative C argonThe role of the expert every last(predicate)eviant c be prevail is complex and unique. The nurse functions as an integral situation of a Multidisciplinary aggroup, providing expert skilled assessment and treat c are, supporting the affected role and the family to make certified choices thereby encouraging the tolerant to continue to make autonomous decisions just slightly their care towards the end of their life.However, often the nurse get out find herself dealing with difficult family dynamics with family members having differing expectations of the type of care that the diligent should be receiving, take into account conflict over treatment methods or strategies and exalted workloads. These issues pile only compound the stresses on the Palliative Care Nurse and to cope with the many dilemmas she must be well armed.The complex necessarily of the terminally ill patient ofs and their families make the multidisciplinary team approach the most(prenominal) effective method of care Staff from a range of disciplines including medical, nursing, social work, dietitian, physiotherapist, pharmacist and others bring diverse and unique skills. As a team they provide an excellent sounding board for ethical dilemmas thereby hopefully- enhancing ethical practice. (Latimer, 1998)The Nurse in her role is require to act as patient advocate and ensure that the patients rights are respected. Unfortunately this advocacy is sometimes descry vetoly as a threat or implied criticism of medical care. Doctors take awayiness to listen to the nurses much finished perspective of patient concerns. Consistency across the team leads to better outcomes for patients. Reinforcing the same information by both medical and nursing staff protagonist to allay patient anxiety far more than than conflicting views on much(prenominal) things as presage control. (Jeffrey, 1995)The mem bers of the Multidisciplinary team sometimes make decisions regarding treatments, which they whitethorn perceive to be of the most benefit to the patient whilst in fact the patient, does non perceive the benefits in quite a the same way. Nurses have more prolonged contact with the patient than most other members of the team cod to the hands on patient care that they do. They often establish a close rapport with the patient and the family and are most likely to be cognisant of the patients likes, dislikes, hopes and dreams and are privy to often delicate and real private details of the patients life. The very fact that the nurse spends so much time with the patient makes them more likely to have k at presentledge of this kind of information. Doctors rounds in a Palliative Care Unit modify the doctor to spend perhaps 30minutes maximum per day in talking to the patient. In the community, appointments times with Doctors are restrictive and Home Visits limited. Patient Nurse depe ndency ratios in hospitals and palliative care units mean that Nurses are spending approximately four hours per day on virtuoso to one patient contact. Again, other team members are very limited in the amount of time they spend with patients payable to the number of clients/patients they whitethorn have. A dietitian for example may spend 15 minutes with a patient twice during their six-week stay in a Palliative Care Unit or 30 minutes as an outpatient during the course of the Terminal illness. Social workers often spend long periods at a time with patients and/or their families in lengthy discussion however these discussions may only take place a check of times over the period of the illness. in that locationfore the Nurse is far more likely to be aware of issues affecting patient care.There can be many difficulties for the Nurse expert providing high tone of voice care to palliative patients whilst respecting their right to autonomy in the setting of the Palliative Care Unit, the role of the Nurse is to incommodestakingly assess the needs of patient and family. These needs may be changelessly changing and there is no room for the Palliative Care Nurse to bugger off complacent in her patient care. Symptoms may be fleshly such as annoying, nausea, and dyspnoea or psychosocial or spiritual. In identifying care needs the nurse must be able to determine who is the most appropriate team member to bear upon to provide optimum charge of these needs. E.g. although the expert nurse will have counselling skills, she must be aware of her limitations and refer on where appropriate to counsellors, psychologist or social worker. Mount (1993) suggests that we must first dish out to animal(prenominal) needs and that to do this we need a detailed knowledge of therapeutics. Skilled listening and precaution to detail are paramount in Palliative Care. Our listening skills non only apply to what the patient is saying, only when what they may be leaving unsaid. Non verbal cues such as facial expressions and demeanour, the need to withstand the door to their room open at all times or to constantly keeps the curtains drawn.In roam for patients to make choices they need to be accurately and appropriately informed, yet Vachon (1993) suggests that whilst caregivers sometimes decide not to regulate patient and family what is likely to happen, at other times they may give withal much negative information not allowing the patient and family to have any hope. Patients need to know at what stage their unsoundness is and their prognosis in order to choose where to spend their remaining time. The ethical communication of information should be timely and desired by the patient, accurate and given in words go outable to the patient and family and conveyed in a gentle, respectful and compassionate manner. (Latimer, 1998) An example of such communication would be that when asked by my patient (speaking about his fungating tumour) When will this thing on my neck stop leaking? I need to gently except truthfully explain that it will most likely continue to leak blood and fluid until he dies exclusively also that we will continue to contain the fluid and downplay the discomfort and attempt to disguise the drainpipe appliance as beat out we can. To not advise him of the eventuality of the fluid discharge continuing is to win him to have false hope and expectations and further disappointment when the discharge continues and probably worsens.However, the nurse needs to gain that some patients do not beseech to have information relayed to them e.g. a patient who did not deprivation to talk about her illness future and continued to deny that her disease was terminal. Dont tell me that, I dont hope you to say those wordsYet respect for patient autonomy demands that patients be given honest answers to their questions. Without this, patients become more uncertain and ineffective to make decisions about their future.Dying patients a re by virtue of their physical and emotional situation, frail and vulnerable their treatment and management during this final phase of their life must be of a high standard both professionally and ethically. The Nurse and other members of the team should seek to do the best for the patient and their family. This includes respecting autonomy, through the provision of truthful information and helping them to set realistic goals part providing genuine attentive care during the full course of the illness.Provision of symptom control hinges on accurate assessment. McCafferty and Beebe (1989) suggest that we dont always make assessment scant(p) by the fact that sometimes we dont readily moot what the patient tells us or the patient may deny having pain or refuse pain relief although they may be hurting. The expert Nurse should remember that the person with the pain is the authority- they are the one who is living the experience and we must believe them if they tell us they have pain. I t is all too easy to allow ones own values and beliefs to cloud our judgement Unfortunately I have seen it happen where a nurse usually not experienced in Palliative nursing will make a statement such as He says he has pain rated 8 out of 10 but he doesnt look distressed or She was laughing and talking with her visitors 5 minutes ago and now shes buzzing for pain relief. Such comments display the Nurses ignorance and lack of understanding of pain. It seems apparent that they do not understand about adaptation or dis parcel of landion or that laughter stimulates the relaxation response throughout the luggage compartment systems by lowering blood pressure, deepening living and releasing endorphins.Also of great importance is the need for the nurse to explore further if a patient denies pain despite indications that they are in fact suffering pain. There may various reasons for denial for example sometimes our language when asking questions about the patients pain may be inappropria te. Some patients may not consider a dull constant ache as pain but an ache. Others may feel sore. Other words such as discomfort and pressure may be used instead of Pain We as nurses need to repress misinterpretation by using such other words.The Nurse needs to explore the issue of pain and help to identify the inception. Location. Intensity, and Quality of the pain help to identify the source. Eg. Bone, visceral or nerve pain. Identifying the source aids in determining the appropriate treatment method. The expert Nurse will be aware that nerve pain will not answer as well to opiates and that neuroleptic agents need to employed. As suggested earlier, as Nurses spend the most time with the patients they are able to obtain the most information on the patients response to pain management plans, they are able to educate patients on the need to take unfaltering analgaesia and they can be the most influential in management of pain (Lindley, Dalton and Fields, 1990).Of course we as nu rses in Palliative Care need to be aware that not all pain will respond well to traditional or orthodox treatments. Seeing a patient in pain and attempt all pharmacological methods without success is distressing for staff as well as the patient and it is consequently that nurses should further attempt to employ other methods such as relaxation, distraction and medicament. Studies have shown that that listening to music disrupts the chronic pain roll. Laughter, Massage and relaxation therapies have also been shown to interrupt this chronic pain cycle (Owens Ehrenreich, 1991) and massaging a dying patients back or feet with oil blends incorporating lavender instils in many cases a looking of peace, contentment and lessening of pain. Heat and cold packs are also said to be beneficial in the treatment of chronic pain however heat applications are said to be contraindicated in patients with brusque vascular supply and in malignancy. Most institutions have policies related to the u se of thermal applications.As most nurses working with palliative patients will know, catgut management is of MAJOR importance The Narcotics we administer to alleviate the symptom of pain have the side effect of causing the symptom of irregularity. Vigilant monitoring of a patients bowel status is essential but it is of great importance that patients are not quizzed about their bowel actions in front of visitors or during meal times. Privately and quietly please Cameron (1992) describes the types of constipation, these being primary and secondary due to pathology or iatrogenic. The goal of bowel management should be the prevention of constipation rather than treatment of constipation and appropriate assessment, regular administration of aperients, appropriate diet and fluids and provision of conditions favourable to bowel evacuation should all be part of the nurses management plan and patient education is paramount here for without the knowledge that opioids will contribute to cons tipation but that regular aperients will counteract this symptom, the patient is unable to make informed choices about his symptom control.Nausea and vomiting are other symptoms the nurse can provide blue-chip assistance in controlling again through adequate assessment and intervention. The nurse needs to be aware of possible takes of nausea and vomiting such as hypercalcaemia, disseminated carcinoma, renal failure and vestibular stimulant particularly in patients with primary brain tumours or secondary cancer deposits. Constipation and radiotherapy, urinary tract infection and chemotherapy- the causes are many and varied. Hogan (1990) suggests that an understanding of the various pharmacological and non-pharmacological interventions is the foundation of symptom control but that the nurses commitment to alleviate the symptoms is the most important variable. Simple techniques like minimising cooking smells, presenting small meals and ensuring offensive odours such as foul linen ba gs from the vicinity can all be employed in adjunction with pharmacological methods to minimise nausea and vomiting. Successful management requires an understanding of the cause of the symptoms.Other symptoms that may give troublesome for the terminally ill patient include oral thrush and stomatitis, diarrhoea, lethargy and insomnia. Dyspnoea can be the cause of great distress and the expert nurse will be aware of the need to employ techniques to minimise discomfort. These may include reducing exertion by the patient, positioning them to allow maximum comfort when breathing and improving air circulation by use of fans or open windows. Humidification by methods such as nebulised saline may also be helpful. Pharmacological methods such as morphine either orally, subcutaneously or as a nebulised solution have also been found to decrease the perception of breathlessness (Chater, 1991) and anxiolitics such as Lorazepam s/l are quite helpful. Reassurance and providing a calm environmen t are also helpful techniques to employ. Distressed relatives around the bedside can further increase the patients respiratory distress and it is at such times that the nurse needs to take them aside and explain to them what is happening and how they can help by remaining calm and distracting the patient or helping them to relax.For the terminally ill patient, being in control is vital and the nurse must appreciate that the patient though suffering an illness from which he will eventually die must be allowed to keep his self respect. This self respect can be eroded enough by the nature of the disease its symptoms and suffering, sorrow and emotional pain. There are times when we as nurses see patients admitted to hospital who have already had their autonomy undermined. Whilst it may have been their wish to stay at home longer or until the end, families may feel the burden of care is too great and that they can no longer cope. This is usually when a new symptom presents that the famil y feel unable to manage. Nurses in the community may sometimes be able to prevent this situation arising by offering a more frequent or higher level of care supported by a Palliative Care Service, education of the family about the patients symptoms and how to help manage them. Sometimes admission is not what the patient wishes but the service is unable to provide appropriate management in the home. There is then an load upon those providing the care to look at all options to enable the patient to achieve his goal of returning home. To be autonomous means to have choice and control in our own lives yet we must stomach that total autonomy is hardly ever possible. Sometimes there are circumstances in which it is not possible to challenge on the patients behalf- times when the patient may wish to have their autonomy eroded. There are times when the patient may not want our advocacy and times when we may not be able to give it- for example controversial ethical issues such as euthanas ia. (Coyle, 1992).The nurse may sometimes develop feelings of helplessness and insecurity because of her unrealistic expectations of herself. The complex role we play in management of the terminally ill sometimes may lead the nurse to think she should be all things to all people the doctors handmaiden the patients advocate, the families sounding board. Sometimes nurses can become over involved, infringing on the autonomy of the patient and the family (Scanlon, 1989) and must be aware of when to withdraw. At times when caring for a patient with uncontrollable physical or emotional pain the nurse may feel herself to be a failure. Add to this the likeliness of inadequate resources and staffing, staff conflict and role conflict and there is a pretty good formula for stress. Abraham and Shandley (1992) list five main sources of work stress. These being 1. Work overload, 2. Difficulties relating to other staff, 3. Difficulties involved in nursing critically ill patients 4.concerns over patient treatment and 5. Nursing patients who fail to improve.This again emphasises the fact that nurses specialising in palliative care are likely to suffer high levels of stress.CONCLUSIONTo help cope with these high demands and continue to maintain the delicate balance between what the patients want and what the health professionals think the patient needs, nurses need to arm themselves with expert knowledge of symptom control, and be well aware of ethical issues related to palliative care. Nurses also need to maintain open active communication with their peers and other members of the facility. We must also hear that even if we do not influence a situation or supply an answer to all needs and if our patients do not maintain total autonomy, it is enough that we have been with them, supporting them as best we can in their journey to the end of their life.Bibliography