Specified Pain Management on Palliative Care
Introduction
Human beings undergoes life cycle, we are born, and we pass through various stages in life until we reached the end which is death. The manner of death of an individual varies; it could be sudden due to accidents, old age and the most common way is through the acquisition of illnesses. However, prior to the death of an individual with a severe illness, he or she is still provided extra care due to his or her condition. Palliative care is the care given to patients that are in the end-stage of the disease. According to the (2007) it is the involvement of holistic care of patients that are in their advanced stage of illness. Healthcare professionals, apart from family members play a huge role in taking palliative care of the patients that are in the last stage of their lives.
Health care professionals particularly the nurses are the front-runners in the management of palliative care of patients. Management of palliative care patients is a difficult task and needs an individual knowledgeable enough to identify the specific needs of the patient. A number of individuals and some of them are even health care workers do not have the appropriate knowledge in handling the patients therefore instead of easing the pain that the patient feels they add additional burden.
Taking care of an ordinary sick patient is not an easy task what more if the patients is already on his or her last stage of illness and even life. The responsibilities of a health worker become doubled. According to (2005) providing care to patients that are dying exhibits huge challenges for health workers particularly the nurses because these patients needs careful management of the signs and symptoms of their illness. Moreover, aside from the patients in palliative care, nurses also play an important role in supporting the family members as death approaches until after the patient’s death.
Working in a palliative care unit in a hospital as a nurse is a very tough job because most of the patients in this unit are suffering from the end stage of their illnesses and deaths for the patients are inevitable. All of the patients are experiencing pain in their body in various degrees and locations. Managing these patients is not an easy task; fortunately I have enough knowledge to handle different cases. A number of new nurses have been accepted in the hospital and some of them are assigned in the palliative care unit, in order to help the new nurses and enhance their knowledge and skills implementing an orientation kit in managing and handling the pains of palliative patients will be made.
This paper examines the principles behind palliative care and the approaches that will be utilised to help in the management of pain. This paper also gives discussion on the ways to control the pain, the various pain problems that patients experience, and the recent advances on palliative care.
Having an orientation kit is important not just in the health care profession but
also other jobs because it helps the newcomers to understand and know the basic necessities in the workplace. In the palliative care unit of hospitals extra care especially when handling the patients because their conditions are extremely sensitive, added to the fact that the patients feel very vulnerable as well as the family members.
The clinical project will be started in the month of April 2007; various data will be gathered from April up to June of 2007. Writing of the whole kit will be on the whole month of July and then will be edited on the first two weeks of August. After editing it a copy will be sent to the head of the hospital for approval. Once the kit is approved, printing will began which is approximately two weeks. A projected introduction of the paper to the newcomers will be on the month of September 2007.
Principles of Palliative Care
According to the (2007) palliative care is the method in which the quality of life of the patients, as well as their families, are enhanced in order to help face the problems related to life-threatening diseases by preventing and relieving the suffering through assessment and identification of pain and problems physically, psychologically and spiritually.
The (2007) has identified the five principles of palliative care and these are:
In palliative care the health care providers must respect the wants and needs
of the patients, as well as, those of the family members. The health workers must also determine who should take care of the patient from the patient itself. It aids the patient to understand the illness and the things he or she must expect in the future. Palliative care helps patients to identify the things that are important to him or her, as well as, the dislikes and likes of the patient.
Palliative care lets the patients understand the death is a significant time for
an individual. The health care workers, particularly the nurses offer ways to ease the pain and physical discomfort of the patient. Nurses must help the patient and the family adjust to the changes if the illness becomes worse. The nurse assures the patient that he or she is not alone and let him or her understand that there are difficulties, and in palliative care the nurse helps the patients look back on his or her life in order to make peace.
The nurses that provide palliative care understand that the family members
also need help in coping up with the situation. Nurses do that through support to family members especially during the time of their grievance.
In palliative care the health care providers are trained professionals and
knows the way system works, it also helps the family members and the patients gain access to good doctors, hospitals and other health services.
It helps the health care providers, as well as, the family members determine
the best ways in caring for dying individuals. It also helps the family members and patients look for funding such as health insurances and organisations.
(1997) enumerated the principles involved in palliative care and these are:
- Confirms life and view death as a natural process in life.
- In palliative care the health worker does not speed nor postpone the death of an individual.
- Provides relief from pain and other symptoms that lead to stress.
- Incorporates the psychological and spiritual aspects of care.
- Gives support to aid the patients in actively live until the time of death approaches.
- Hive support to aid the families of the patients in coping up during illness and after death.
Essential Components of Palliative Care
discussed that the significant components of palliative care are the efficient control of the symptoms, effective communication with the patients and their families. It is also important for nurses to help the patients in the rehabilitation with the objective of maximising the patient’s independence as possible. Life threatening illnesses progresses and as it does the nurses and the family members must continuously care the patient.
Depression, anxiety, and confusion
Upon receiving the news most of the patients and even family members experience depression. According to (1997) the emotional and cognitive changes in patients with end-stagedisease manifest both psychological and biological impacts ofthe treatment and medical condition. discussed that the psychological adjustmentreactions after diagnosis or relapse often include fear, sadness,perplexity, and anger. The psychological adjustments can be resolved within a few weekswith the aid of the patients’ own personal feelings, support of the family members, and professional care.
Symptoms and Signs of Depression
discussed that the signs and symptoms of depression are divided into somatic and psychological and these are:
Somatic
- The energy decreases and the patients feel fatigue.
- The sleep is often disturbed and the patient is waking up in the wee hours of the morning.
- The appetite is reduced.
- Psychomotor agitation
Psychological
- The mood of the patient is always low and it is usually worst in the morning.
- Lost of interest and pleasure.
- Concentration and attention is decreased.
- Indecisiveness
- The patient feels guilt and worthlessness.
- The insights about the future are pessimistic and hopeless.
- Thinking of committing suicide.
Symptoms and signs of confusion
- The patient reduces his or her awareness of the surroundings.
- The strength and quality of attention is diminished.
- The quality of abstract thinking and comprehension is decreased.
- The patient feels disoriented in time, place, and person.
- The patient has hallucinations and visual distortions.
- Temporary delusions.
- Extreme emotional disturbance and under activity.
- Disturbed cycle of sleep.
- Emotional disturbance.
Approaches to pain management in palliative care
Palliative care is the care given to patients that are in their last stage of life, and usually these patients experience pains in various parts of their body. (2007) discussed the different approaches to pain management during palliative care and these are:
- Reduce the noxious stimulus
In decreasing the noxious stimulus the patient is deliberated to appropriately provide proper treatment of the fundamental cause of the pain through various measures such as chemotherapy, radiotherapy and surgery.
- Raise the pain threshold
Most of the palliative care patients feel depressed, anxious, and confused upon receiving the news thus the pain that they are feeling worsens. Support of the health workers does not necessarily help the some of the patients cope up with the situation. In this case, aside from the support of the nurses, family, it is necessary to require support from the church and professionals.
Aside from the family members the use of drugs could also aid in raising the threshold of pain of the patients, there are anti-depressant drugs in the market that could help suppress the feelings of the patients.
The easiest way to suppress pain due to depression is to make certain that the patients get enough sleep at night.
- Consider an opoid
Giving analgesic to patients also helps suppress the pains of an individual particularly during the end-stage of life of an individual.
Pharmacologic Approaches to Pain Management
According to (2007) the world Health Organization developed a three-step pahramacological approach to pain management and these are:
Nonopioid Analgesics. Ceiling Effects of Nonopioid Analgesics
There are two types of nonpioid analgesics and these are the acetaminophen
and the nonsteroidal anti-inflammatory drugs.
Acetaminophen- it is a useful medicine for coanalgesic situation such as headache and it does not have anti-inflammatory effects, however if the patient has hepatitis and has high alcohol intake the risks would be increased.
Nonsteroidal Anti-Inflammatory Drugs- it is a useful coanalgesics and efficient in decreasing the bone and inflammatory pain. However the adverse effects include Gastrophy, Renal failure and inhibition of platelet aggregation.
Opioids reach the peak plasma concentration 60 to 90 minutes after it is
induced orally, 30 minutes if it is induced through injection, 6 minutes after intravenous injection and they are removed from the body the liver conjugates the opioids, the kidney excretes the metabolites, the metabolic pathways do not clog, each opioid metabolite has a half life which has an efficiency approximately 3 to 4 hours, therefore, steady state of the concentration of plasma is achieved daily.
Nonpharmacologic Approaches to Pain Management
(2005) nonpharmacologic interventions are significant additions in reducing the pain, disturbance of mood and even aid in increasing the quality of life of the patients. discussed the four interventions utilised in the nanpharmocologic approach and these are:
Psychological Interventions- a health worker particularly nurses in the palliative care units must identify the psychological issues such as beliefs and ways of coping because it is a relevant aspect in the pain treatment. The fear of death and advancement of the disease is a common occurrence among palliative patients however the level of psychological distress differs among patients ( 2004). Moreover, Brietbart et al discussed that psychiatric disorders often occurs among patients that experienced pain.
Cognitive Behavioural Intervention- in cognitive interventions the nurses must identify and determine the track of their pain, the emotions and thoughts are determined, and follow the increase of the severity of pain. Controlling the pain and perceiving that they can decrease the pain that they feel could decrease the pain that a patient feels ( 2003).
Behavioural Interventions- in behaviour interventions analysis of the behaviour of an individual is done and the condition is evaluated, prevented and treated. Behavioural interventions such as music therapy, meditation, and hypnosis are utilised. According to the study of (2002) hypnosis has been efficient in suppressing the pain during postoperative processes.
Psychosocial Interventions- (2005) found out that in treating the pain of cancer patients it involves three steps and these are education about cancer, hypnosis and imagery methods. Letting patients understand the disease and assess the pain helps patients overcome pains.
In the study of (2005) they found out that health workers who joined the cognitive-behavioural program have reported that it enhanced the self-efficiency in helping the patients control the pain that they feel, health workers become less strain because of the education they got. Therefore educating health providers about pain helps ease the pain of the patients because they become more knowledgeable.
Difficult Pain Problems
(1997) identified and discussed the three pains patients in the palliative care experience and these are:
Neuropathic pain- neuropathic pain is caused by damaged tissues wherein it may be produced by a tumour penetrating the nervous tissues, surgery, radiotherapy, and chemotherapy can also contribute to the neuropathic pain. The characteristics of neuropathic pain are burning, stinging, aching, and stabbing, which can either be spontaneous or not.
Treatment could be through the use of opoids or through counter irritation, with the emergence of alternative medicines such as acupuncture some of the patients with neuropathic pain use it.
Incident Pain- it is a pain caused by voluntary action like movement of the patients with pain. The treatments of incident pain are through physiotherapy and occupational therapy, and surgery.
Visceral Pain- it can be difficult to describe however if it is determined bloating and nausea are the symptoms, however there are organs in the body that experience visceral pain such as the epigastric pain. The causes of visceral pain in cancer patients are the growth of tumour, invasion of the tumour in the parietal surfaces, distension due to blockage in the ducts, bowel, bladder due to tumour, inflammation, rupture in the viscous, and the release of the pancreatic enzymes. Treatment with drugs such as analgesics and non-drug measures such as alternative medicines could be utilised to treat visceral pain.
Advances in Palliative Care
Advances in Pain Management
(2000) discussed that there are new drugs identified for management of pain and these are:
- Bisphosponates blocks and treats bony metastases and the pain in various types of cancers.
- New types of opoids are created which are long acting.
- Methodically administered anaesthetics like parenteral lignocaine.
- Psychostimulants that counters the effects of opids.
- Topical anaesthetics
- Specialised pain relieving procedures like nerve blocks.
Advances in alleviating other symptoms
Aside from the advances in pain management Billings also discussed the advances in alleviating other symptoms that contributes to the pain of the patients and these are:
Gastrointestinal Symptoms- patients are administered with prokinetic drugs new serotonin antagonist antiemetics has helped patients manage the symptoms in gastrointestinal cancer such as nausea and vomiting. In the case of AIDS the drugs helped in alleviating and managing intestinal obstruction.
Dyspnoea- the addition of benzodiazepines to opioids and oxygen has helped in management of anxiety of patients in the palliative care.
Confusional States- in recent studies researchers have determined that haloperidol and chlorpromazine in low doses have helped enhance the condition of AIDS patients and the neuropletics improved the organisational thinking of patients with emotional disturbances.
Depression and use of psychostimulants- nurses and health workers must assess the patients and identify the symptoms, in this process health workers can identify whether the patients experiences depression or not. Psychostimulants are the new drugs in the treatment of depression due to terminal illness.
Advancement in the institutions
The world has now seen the importance of palliative care of patients, therefore a number of countries have started to acknowledge and incorporate it in their health system. According to (2005), 20 percent of American hospitals (1,100) have developed palliative care units and/or consultation teams. Increasingly, palliative care is identified as part of quality medical care, at the same time, a series of initiatives has been launched to foster hospital- and hospice-based initiatives that will bridge the gap in services, enhance care, and support hospice teams that provide palliative care consultations to hospitalized patients.
Conclusion
Palliative care is not an easy task to be undertaken by a medical professional, it needs knowledgeable and skilful health workers that could address the needs of these sensitive patients. Nurses must have the basic knowledge in pain management in order to help patients that are in their palliative stage in the disease. Through having an orientation kit that states the basic ideas on pain management on palliative care and the new advances in pain management it would greatly help newcomers in addressing the needs of their patients.
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