INTRODUCTION:

In the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) 2013-2020, palliative care is explicitly recognised as part of the comprehensive services required for the management of noncommunicable diseases¹. Palliative care is required for a wide range of diseases².

The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Palliative care nursing involves the assessment, diagnosis, and treatment of human responses to actual or potentially life-limiting illness. It also necessitates a dynamic, caring relationship with the patient and family to reduce suffering³.

Case Summary:

The patient identified was a 54 year old male with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD)⁴ with history of hypertension, hyperlipidism and hypothyroidism and for this case reflection I will call him as Mr. X. He came to the emergency with complaints of acute shortness of breath, forgetfulness, weakness, fatigue, swelling of bilateral lower extremities. His vital signs were as Temperature: 97.6ºF, Heart rate- 86 bpm, Respiratory rate: 34/min, BP: 100/54mmHg, Oxygen Saturation: 90% on room air. 2+ pitting edema bilateral lower extremities.

Table 1 Investigations done for the patient

S.No.	Investigations done	Reason why it was done
1.	Blood counts	Rule out infection, anemia
2.	ABG	Acidodis or alkalosis
3.	LFT	Liver function
4.	KFT	Kidney function
5.	Chest Xray	Assess lungs and heart
6.	ECG	Cardiac abnormality
7.	Echocardiogram	Assess heart and valves

Treatment and Management

Mr. X was positioned in fowler’s position and BiPAP ventillatory support to reduce bronchospasm, shortness of breath and improve oxygen saturation, nebulisation with bronchodilators, antihypertensives, antilipidemic agents, thyroid hormone supplementation as the patient had history of hypertension, hyperlipidism and hypothyroidism. He was also closely and frequently monitored.

Mr. X was not able to maintain the expected saturation so he was put on Assist control mode of ventilation, tidal volume of 6ml/kg, initial FiO2 100%, respiratory rate 26 per minute to compensate for metabolic acidosis and PEEP of 7mm Hg. He was anxious of various procedures being done and was also tachycardic.

The consultants from pulmonary medicine, cardiac centre and critical care were consulted along with emergency medicine⁵. Physiotherapists and dietician was also involved in the care.

The multidisciplinary contributions were helpful as the patient can be managed in a holistic manner and hence help to improve the outcome of the patient.

Learning of Palliative Care Principles and Practice:

According to WHO, “Palliative care is an approach that improves the quality of life of patients and their families facing the problem 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”.

It is of utmost importance to understand that palliative care should have started early for Mr. X after the diagnosis. We should use easy to understand language and help patients to take decisions suitable to them and their family⁶. Good communication would help to relieve anxiety of the patient and thereby reflecting in vital parameters for Mr X. Following the Principles of Ethics Mr. X should have been given the opportunity of knowing about Advanced Directive. Spiritual and religious needs should have also been addressed which are usually not taken care of in the highly mechanical unit of critical care⁷. Ethical issues need to be handled delicately and sensitively in palliative care settings, within the framework of the traditions and culture of the society and financial constraints⁸. Assessment of pain and its management is of utmost importance⁹. Mr X as the patient in intensive care may not be able to report pain due to intubation and inability to express so the other methods of communication should have been adopted like sign boards. Explanation of the nursing procedures was done prior to the start of procedure. Mr X also had fatigue and weakness for which the underlying cause of hypoxia was being treated; other methods of counselling could also have been used. Since Mr X is earning member of his family and also has responsibility of his three children- two daughters and one son. He was anxious and also had fear of death when brought in the emergency. He had unfinished responsibilities of marrying his daughters. He felt helpless as his condition was worsening due to comorbid illnesses. Moreover, one family member had to accompany the patient and whole family was disturbed. So, supportive care would have helped him and his family. Effective communication would help in decreasing the distress in patient. Mr X after intubation may develop delirium so effective steps were taken prevent ICU delirium like orientation to time and place etc.

Changes in new learning at personal level:

According to National Cancer Institute palliative care addresses the person as a whole and not only the disease. Palliative care has improved my perspective of holistic care of patient with life threatening illnesses. Palliative care helps to improve quality of life of patient and the caregiver¹⁰. Palliative care can be applied to all chronic illnesses. It starts right from the diagnosis of the illness till death. It also includes all aspects of care including physical, psychological, social and spiritual. It is a team work of physicians, nurses, physiotherapists, nutritionists, support staff and volunteers¹¹. It caters to the management of various symptoms experienced by the patient. As recognized by Saunders, nurses have constant presence with the patients. Nurses are eccentric to create healing relationship with patients and families¹². Good and effective communication is a key component in palliative care. So better patient care can be provided following the principles of palliative care.

Changes in new learning at professional level:

It is paramount to teach and explain about palliative care to the students and thereby improving the patient care¹³. We also need to sensitize the students that palliative care should be practiced by all nurses caring patients with chronic illnesses. Nurses have maximum contact with the patients so we have to be very vigilant and compassionate in the care we provide to the patients¹⁴. Patients can also communicate more freely with us so adoption of effective communication techniques are of utmost importance for us. Sharing the knowledge regarding ethics in palliative care, communication, symptom management, pain, fatigue, anxiety, depression, spiritual and religious issues, palliative care emergencies, end of life care, grief and bereavement with my students, staff and my colleagues will definitely help in providing holistic care to the patients and caregivers and thereby improving their quality of life.

This new learning of palliative care has added to my existing body of knowledge and skills. There were so many aspects which we miss in the highly technical machine oriented care. If the palliative care is incorporated at right time we may reduce the number of hospitalization and the various complications.

Physical care:

It is cardinal to identify the various symptoms and their management including pain, breathing difficulty, fatigue, weakness, depression and also the care of bedridden patients.

Psychosocial care:

There are various psychological concerns like fear, anger, anxiety, depression that occur in patients and the various coping mechanism that would help address these issues.

Spiritual care:

The concept of spirituality and religiosity play a significant role in developing positive coping mechanisms and thereby improving the quality of life.

Issues of Communication with patient and family:

Good and effective communication is foremost in treatment and management of patients. Learning of good communication skills help in relieving suffering of patients and their families.

Ethical Issues:

The principles of ethics – autonomy, beneficence, Non malficence and Justice are important while caring for the patients and should be followed.

Policy and innovations:

Integration of palliative care in the curriculum with clinical experience for nursing students is vital. Palliative care can also be an area of importance in the research and we need to build evidence to models of palliative care for Indian setting. Multidisciplinary team work is an integral part of palliative care. Continuous in service education programmes should be conducted for nurses to impart knowledge and improve skills in palliative care.

CONCLUSION:

Palliative care concepts should be taken into account right from the admission of patient and beginning of care. It helps in optimizing the quality of care for both patient and their families. Incorporating the principles of ethics, symptom management, communication, addressing spiritual and religious issues would improve the nursing care being provided to the patients. It is of utmost importance for nurses to practice self reflection to expand their knowledge and skills. Nursing students should be taught and motivated to reflect on their care provided to the patients, identify the lacunae in the care and finally improve the standard of nursing and provide compassionate care.

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Received on 04.05.2021 Modified on 16.10.2021

Asian J. Nursing Education and Research. 2022; 12(2):242-244.

DOI: 10.52711/2349-2996.2022.00050