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. Palliative care:

  • provides relief from pain and other distressing symptoms;
  • affirms life and regards dying as a normal process;
  • intends neither to hasten or postpone death;
  • integrates the psychological and spiritual aspects of patient care;
  • offers a support system to help patients live as actively as possible until death;
  • offers a support system to help the family cope during the patients illness and in their own bereavement;
  • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
  • will enhance quality of life, and may also positively influence the course of illness;
  • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

End of life care is used interchangeably with palliative care

Sensory changes

Decreased oxygenation and circulation to the brain cause alterations to sensory input and interpretation. These can include blurred vision, decreased sense of taste and smell, and decreased pain or touch perception. The blink reflex can be lost causing patients to stare. Hearing is the last sense to remain intact.

Circulatory and respiratory changes

With decreased oxygenation and altered circulation causing metabolic changes, the heart rate weakens and the blood pressure falls. Temperature may increase due to dysfunction of the hypothalamus.

Respiration may be rapid or slow shallow and irregular. Breath sounds may become wet and noisy, termed death rattle. This is due to mouth breathing, accumulation of mucous in the airways and the inability of the patient to clear the mucous due to altered gag reflex and muscle weakness. Cheyne-stokes respiration is an abnormal pattern of breathing characterized by alternating periods of apnoea and deep, rapid breathing. This is seen close to death.

There is decreased circulation, especially noticeable on the skin. The extremities become pale, mottled, cyanotic, and cool. This starts in the lower extremities, progressing to the arms and hand, and then to the torso.

Urinary system 

There is a gradual decrease in output, incontinence of urine or inability to urinate.

Gastrointestinal system

There is a slowing of the GI tract ability and possible cessation of function, accumulation of gas, distension and nausea, incontinence.

Musculoskeletal system

Gradual loss of the ability to move, sagging of the jaw, difficulty speaking, dyshagia, loss of gag reflex, jerking movements

 

Nursing management

Pain

Acute or chronic pain may be a major symptom associated with terminal illness. Physical and emotional irritants may aggravate pain.

  • Assess pain using PQRST
  • Minimise irritants
  • administer regular analgesia
  • Provide complementary therapy: guided imagery, distraction
  • Evaluate effectiveness of pain relief measures

Delirium

This is a state characterized by confusion, disorientation, incoherence, hallucinations, and fear and anxiety. It may be misdiagnosed as depression or psychosis. The use of opioid analgesics may cause delirium.

  • Perform a thorough assessment for reversible cause: UTI, constipation
  • Provide a quiet, well-lit room
  • Reorientate the person
  • administer benzos as needed
  • Provide family with emotional support

Restlessness

This may occur as death approaches and cerebral metabolism slows.

  • Assess for spiritual distress
  • Use soothing music
  • Limit visitor numbers

Dysphagia

May occur due to extreme weakness or changes in level of consciousness.

  • Suction as needed
  • Alternate route of medication administration

Dehydration

This may occur during the last days of life but thirst is rare during this time

  • Assess mucous membranes
  • maintain complete oral cares
  • Encourage consumption of ice chips or use moist cloths
  • Apply lubricant to lips as needed

Dyspnoea

This may be accompanied by a fear of suffocation, coughing and shifting mucous becomes difficult.

  • Assess respiratory function
  • Elevate the head of the bed
  • O2 therapy
  • Suction as needed

Weakness and fatigue

Metabolic demands related to disease contributes to weakness

  • Assess tolerance for activities
  • Time interventions to conserve energy
  • Assist the patient to complete tasks
  • Provide rest periods

Myoclonus

This is mild to severe muscle jerking commonly associated with high doses of opioids

  • Consider changes to analgesia
  • discus drug therapy with the doctor
  • Assess for initial onset and duration

Skin breakdown

Immobility, urinary and bowel incontinence lead to a high risk of skin break down. Circulation to the skin decrease as dying progresses

  • Assess the skin
  • Keep skin dry  and clean
  • Use blankets for warmth
  • Prevent the effects of shearing and friction

Bowel patterns

Constipation can be caused by lack of mobility and also through the use of opioid medication.

  • Assess bowel function
  • Assess for and remove fecal impaction
  • Encourage movement as tolerated
  • Use laxatives as needed

Urinary incontinence

This may result from disease progression or changes in the level of consciousness

  • Asses output
  • Use pads for incontinence
  • Monitor for skin breakdown due to moistness

Anorexia, Nausea and Vomiting

Constipation can cause nausea, vomiting and anorexia. It may also be attributed to the disease process

  • Assess for nausea and vomiting
  • Discuss modification of drug therapy
  • Provide antiemetics
  • Offer frequent, small portions of food
  • Provide frequent mouth care

 

 

References

Harrington, A., & Hegarty, M. (2008). Palliative care. In D. Brown & H. Edwards (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems (2nd ed., pp. 153–167). Sydney, Australia: Mosby Elsevier.

 

 

 

 

 

 

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