Palliative Care

  Introduction

The ever growing concern in the community regarding the cost and quality of health care has exerted a lot of pressure on the health care services delivery, where expectations for cost effectiveness and high quality of health care services are so high (Burt, Shipman, & White, 2006). There are high expectations for well coordinated healthcare services with clarity of the roles within the service delivery with minimal duplications. Among the most demanding health care services in the community has been the palliative care, which is the approach meant to enhance the life quality of the patient concerned, together with alleviating the different types of problems through which the family and the patient undergo in the course of their life-threatening illnesses (Coupland, Lee, Madden, Sykes, Møller, & Davies, 2010). The palliative care, in this case, is achieved by way of relief and prevention of suffering by ensuring the problem identification is done early enough and execution of impeccable assessment, treatment of pain, as well as offering psychological, physical, and spiritual relief for the patient (Penrod, Dellenbaugh, Hochman, Maciejewski & Morrison, 2006).

This essay seeks to demonstrate the critical knowledge regarding the external influences that directly influence the end of life care, together with the strategies applied by the concerned practitioners in facilitating the delivery of palliative care services of the required quality. On the other hand, the essay will also seek to evaluate the variable factors, including the social, physical, and psychological factors, together with their respective impacts on the experience of the client in relation to the provided palliative care. The information, analysis and proposals are made in relation to the case study provided herein. In essence, the references made to the case study are strictly within the context of care delivery, together with the related issues, which have a direct impact on the health outcome of the patients.

Patient’s Case Study

The palliative health care focused herein concerns a patient in a hospital based in the United Kingdom. For the purposes of data protection and confidentiality, the patient will be referred to by the name Janet throughout the discussion. Mrs. Janet is admitted into the palliative care unit 28 years following the diagnosis that revealed that she had cervical cancer. Her suffering from this had taken quite a long time, and exhibited a significant level of complexity together with a painful history of the course. The cancer diagnosis had been done and approved when she was 30 years and this was followed by a hysterectomy. A year afterwards, the patient experienced a cervical cancer recurrence in the pelvis, which was handled using 5-fluorouracil and cisplatin as the form of chemotherapy. After this, the patient was subjected to radiation therapy after it was noticed that the condition was not getting better.

Mrs. Janet then underwent persistent proctosigmoiditis that was radiation induced, which was most likely to have been exacerbated by the radio-sensitizing action effects of the 5-fluorouracil. In addition, the patient underwent surgery for colostomy placement. In addition, the patient experienced frequent damages to the bladder, radiation cystitis, and she eventually had to undergo urostomy placement nine year following the radiation therapy. Due to the strictures to the ureter, there was need for the patient to undergo a replacement of the bilateral nephrostomy tube, and also required a regular change of stents at an interval of six weeks. A year later, after the patient had developed an obstruction on her bowel, there was need for the patient to undergo exploratory laparotomy. She also underwent extensive restriction of the bowel, followed by the replacement of the gastrostomy.

What was ascertained was the insufficiency of the bowel to do absorption of the ingested nutrients, and this meant there was a need for a total parenteral nutrition. The patient was also subjected to a total replacement of the right hip through a surgery following the development of a fracture in her hip. Some years afterwards, the patient was discovered to have a vesicovaginal fistula. Even with the aggressive management of the condition, the patient demonstrated persistence in the skin excoriation as a result of the leakage of urine.

Mrs. Janet underwent numerous hospitalizations after the original diagnosis she had gone through, together with an endless experience of admissions in the intensive care unit. On the other hand, the patient went through a host of infections, amongst which was the abdominal abscess, together with the many ulcerations of the skin she experienced. Other medical complications discovered included deep vein thrombosis, chronic renal insufficiency, depression, and pulmonary embolism. The patient had a constant pain problem even with the extensive treatments she underwent. There was a low pains in the back as complained by the patient and also had radiculopathy in her left leg.

Mrs. Janet complained of a persistent throbbing sensation within her lower extremities bilateral to the neuropathy. Additionally, the patient complained of pains in the nephrostomy tubes, and the pain was so intense at some moments, resulting in the sleepless nights. The constant excoriation of the skin caused by leakages from her vesicovaginal fistula caused her extreme pains, and this posed a significant challenge in the treatment. The patient had multiple wounds on her skin together with other cellulitis areas. Mrs. Janet was undergoing both immediate and extended release pregabalin, morphine, and methadone for the purpose of alleviating the areas she experienced chronic pain, since the neurolytic blocks had shown no effectiveness in managing the condition.

Mrs. Janet was admitted to this facility when she was 58 years of age, and a widow, a mother of four children, all of which were adults. Due to her bed-bound condition that required a 24-hour care every day, the children had the obligation of providing the needed care every night. However, following their work commitments, there was needed to hire a caregiver to offer the required care services during the day when they were away. Following an extensive delibation, which meant she had to spend extensive hours in bed, the patient was admitted to the palliative care unit for the inpatients following a successive fall at home. Mrs. Janet informed the team of her desire not to continue undertaking the therapies that were meant to prolong her life and also wished that the artificial nutrition be discontinued.

The patient was absolutely convinced that the cancer condition she had had been completely cured, but the aftermath adverse effects were unbearable and had become overwhelming and unmanageable. It was as a result of this that Mrs. Janet requested for the withdrawal of the artificial nutrition support on which she had been put as she opted for a comfortable end of her life as opposed to the painful endless experiences she underwent. The concerned team was obliged to seek for assistance from the social services in order to determine whether any extra resources could be offered, but all the needed support was constantly offered to her. The team sort for psychiatry opinion and the result of the examination proved that the patient was effectively competent.

On the other hand, despite the depression in the patient, she was capable of understanding and making decisions on her own. Her children, who constituted her immediate family, held a meeting and agreed to offer support for her decision. Despite the difficulty in the prediction of her prognosis, it was thought to take about two weeks, and this was significantly determined by the amount of oral intakes she could comfortably sustain. Due to the amount of care that the patient need, the family was no longer able to offer the care from home, prompting her transfer to the inpatient hospice. The patient passed on comfortably two weeks following her admission in the facility.

External influences which have a direct effect on end of life care

Palliative care is generally meant to provide relief from the pain suffered by the patient together with the distress that comes with the health condition of the patient (Pyenson, B., Connor, Fitch & Kinzbrunner, 2004). For instance, the patient under study experiences endless pains which come as a result of the continuous skin ulcerations due to the leakage of urine (Twycross, 2003). In essence, the palliative care given to the patient under study is thus meant to affirm her life, as well as making the dying process look normal. Similarly, the care is meant to alleviate the different forms of suffering, particularly psychological and economic, through which the family of the patient goes. The dying process is thus not meant not to speed up nor post pone the death of the person (Kinley, Froggatt & Bennett, 2013). The palliative care is inclusive of the psychological and spiritual state of the patient. For instance, the patient has to undergo numerous psychiatric examinations during the process of care in order to ascertain the competitiveness of the patient in making decisions that directly affect her medical condition (World Health Organization, 2009).

In this respect, therefore, the process is sufficient to offer the required support system that enables the patient live a life that is as active as possible till death (Meier, 2011). The support system provided during this period is important in helping the family of the patient cope with the moments during which the family member goes through the period of illness (Richfield, Jones & Alty, 2013). In addition, the team approach process is important in helping address the different needs of the family and the patient, since it incorporates bereavement counseling, and this will significantly improve the life quality of both the patient and the family.

There exist various factors that influence the end-of life care provided to the patients with life-threatening health conditions. Amongst these are the economic factors, which determine the patient’s ability to meet the expenses that come along with specialized care of the condition (Tibi-Levy, Le & De, 2006). Mrs. Janet is able to access quality care services owing to her financial abilities. On the contrary, patients from low social classes fail to afford the healthcare insurance cover hence making it difficult for them to access such specialized health services. Cultural factors are also very important in determining the quality of care that the patient is bound to receive (Watson, 2010). For instance, it is very important that the nursing staff understands the different cultural practices and beliefs of the respective patient in order to offer the required care without contravening the beliefs of the society from which the patient comes (Watson, 2010). Mrs. Janet is able to find befitting health care services the health care providers within the facility and the society around have sufficient expertise in culture-based health care services. On the other hand, the family members to the patient, who are her children, have been taught about the better ways to provide the required care from home and this is of significant importance in ensuring culture-compliant health care services (Tan, Seah, Chua, Lim, & Phua, 2014).

The quality of care and its effect in alleviating the chronic life-threatening health condition is significantly determined by the availability of the relevant societal facilities for promoting health. For instance, the availability, accessibility, and effectiveness of hospice facilities determine the quality f care the patient is bound to receive. As seen from this case study, the care for the patient with end-life diseases initially receives healthcare services from their families together with the social health workers from their homes. However, as evident in Janet’s case, the care needed by the patient becomes more complex as the condition advances, requiring the hospice facility intervention. The availability and availability of proper resources is important in relieving the family from the burden of care provision, as well as reliving the patient of the recurrent and unbearable pain and suffering.

Additionally, the commitment and agenda of the government and other related authorities towards improved healthcare determines the quality of care to be received by palliative care patients. For instance, the government has the obligation of allocating resources, particularly finances, which should be used in purchase of necessary equipments for life supporting, as well as hiring of qualified personnel to offer palliative care. Misallocation of resources by the authority could lead to poor quality of services for the patients.

In addition, the counseling sessions, as incorporated in the palliative care, are important factor in influencing the illness course, especially when introduced early enough, together with the other forms of therapy meant for prolonging the life of the patient (Thomas, Hudson, Oldham, Kelly & Trauer, 2010). Such therapies, as seen under the case of the patient, include radiation and chemotherapies, as well as the investigations which are required in order to facilitate comprehensive understanding and management of the clinical complications that are significantly distressing (Steinhause, Christakis, Clipp & McIntyre, Tulsky, 2000). The professionals involved in the provision of palliative care work in teams, which are constituted by the doctors, nurses, pastoral care workers, social workers and volunteers.

These teams are expected to work together with the specialists, GPs, together with all the organizations in the community that are tasked with the management of day-to-day support and care of the patients (Watson, 2010). The major objective of these groups is to ensure that the family and the patient receive the most ideal care possible in the facility and the community. The palliative care is provided within variable settings, which include homes, within the facilities for aged care, in the acute hospitals, as well as the hospice or units for palliative care (O’Brien, Whitehead, Murphy, Mitchell & Jack, 2012). The care provided in homes proves to be a big commitment for the carers. Anyone considering becoming a home carer must be ready to discuss with the concerned doctor of the patient, or the community, or the nurses involved in palliative care (Murray, Boyd, & Sheikh, 2005). The availability of help for the potential home carers of the patients with life-threatening conditions means there is no reason for fear of caring for this patients at home. However, if the home carer does not feel like he or she can effectively manage the provision of the required services, they do not have to feel guilty for the same.

Strategies Employed to Facilitate the Delivery of Quality Palliative Care Services

In order to ensure delivery of quality services in the palliative care unit, the health personnel can employ numerous strategies, amongst which are the structural elements of the setup (Smith, Brick, O’Hara & Normand, 2014). For instance, interdisciplinary team among the palliative care providers is key in ensuring the patients receive the best services and better health care to alleviate their conditions. This means that the nurses, physicians, spiritual counselors, social workers, volunteers, aides and pharmacists have the responsibility of ensuring a close team spirit to ensure that there is no gap between the services provided by each discipline (Gardiner, Ingleton, Seymour, Cobb, Noble, Bennett & Ryan, 2012). In reference to the case of Mrs.Janet, for instance, there can be seen that the health personnel demonstrate a very close team spirit, particularly evident in the manner the side effects of the different forms of therapies are managed effectively.

In addition, the quality of service offered in palliative care units can be improved through ensuring sufficient ration of the health care personnel to that of the patients under care (Sigurdardottir, Kaasa, Rosland, Bausewein & Haugen, 2004). In this case, for instance, the palliative care must guarantee prompt and effective attention to the patients when needed. In Janet’s case, for instance, the numerous complications arising from the side effects of the cancer therapies require instant attention to alleviate the painful experience of the same (Reynolds, 2008). Therefore, the increase in the number of staff is important in ensuring that the patients do not go through pain without timely attention.

Quality health care can also be enhanced through comprehensive determination and documentation of the goals for both the patient and the family concerning the care (Ringdal, Jordhoy, & Kaasa, 2002). For instance, there should be an advance care planning, in which the physician arrange for treatment for life sustenance as demanded by the family or the patient. In the case of Mrs. Janet, the providers of the palliative care are quick to heed to the desires for both the family and the patient the facility withdraws the artificial nutrition and other life sustaining services to facilitate a comfortable death of the patient, which is an ideal way of alleviating the painful experience of the patient (Johnson & Gadoud, 2011). The health care value is expressed in terms of the quality to cost ration. This means that improvement of the value can be done through improvement of the quality, reduction of cost, or both (Eyre, 2010). The diffusion of innovations where the program is aimed at targeting the chronically ill population is an ideal way of increasing the value through reduction of the costs and improving the quality of health care for the sickest or most complex patient conditions (Scott, 2001).

The quality of care provided for the end-of-life patient care can be improved through increasing the access to the hospice and palliative care services for the patients in need (Gott, Ingleton & Gardiner, 2009). For instance, it is evident that the patients in this stage of illness experience endless medical problems, including recurrent pain and development of new health conditions, which require prompt attention from the service providers (Milligan, 2012). Treatment of distressing symptoms has been proven independently to reduce the complications that arise during illness as well as the hospitalization of the patients.

The hospice and palliative team often meet with the patients, together with their families in order to facilitate the establishment of realistic and appropriate goals and objectives for the care given, as well as offering support for the family at the time of crises (Rowlands & Noble, 2008). In addition, such meetings and discussions are important in planning for safe transitions from the hospitals to other settings that are more supportive for the patients, such as the home hospice, home care, inpatient hospice care, and the nursing home care with hospice (Payne, Seymour & Ingleton, 2004)