Introduction to Palliative and End of Life Care

• Palliative care is a care that focuses on a patient and his family as they approach a life-threatening illness.
• It begins from the day of diagnosis of a life-threatening illness.
• Palliative care encompasses both the patient and their environment and how their illness impacts on everything around them.
• Palliative care covers the physical, psychological, social, and spiritual elements of care.
• Palliative care is concerned about the patient's home, people in the household, the suffering of the patient, and its impact on the family, etc.
• End of life care is a small part of the wider palliative care.
• Palliative care involves several elements, so working together as a multidisciplinary team is important.

What is Palliative Care?

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with the 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, psychological, and spiritual.

World Health Organisation

• Provides relief from pain and other distressing symptoms.
• Affirms Life and regards dying as a normal process.
• Intends neither to hasten nor postpone death.
• Integrates the psychological and spiritual aspect of patients' 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 patient's 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 positively influence the course of an illness.
• Is applicable early in the course of illness in conjunction with other treatments that are intended to prolong life such as chemotherapy or radiation therapy, including investigations needed to better understand and manage distressing clinical complications.

Palliative Care Approach

• A specialist approach to the care of patients facing death relatively soon.
• Wholistic approach - by applying the best principles of medical science in the context of the whole person and those close to them.
• Helping people achieve their goals in the end of life.
• Needs paying attention to details.

Core Skills in Palliative Care

• Every health care professional encounters death and therefore needs core palliative care skills.
• Core skills relate to:
• Attitude
• Symptom relief
• Helping people to find their inner resources

• Physical
  • What are the reversible symptoms?
• Psychological/emotional
  • What is causing anxiety?
• Social
  • What can be done to support their social structure?
• Spiritual
  • What are their spiritual needs?

Case Example:

A 45-year-old lady has cancer of the cervix, she has 5 children but has been widowed. She has pain from her cancer radiating down her right leg. You are asked to see her. Outline the issues you may want to address:

• Her physical pain
• Her possible psychological issues – fears, concerns
• Her social issues – children, no husband, housing, care
• Her spiritual issues – does she attach any meaning to her illness, does she have a faith, is it helpful?

Physical Pain or Symptoms

• Is the patient in pain?
• Does the patient have any physical symptoms?
  • Breathlessness
  • Nausea/vomiting
  • Constipation
  • Pain from the nerves
  • Pain due to the cancer

Psychological

• Help the patient manage their own emotional distress.
• Ensure your patient has the appropriate support network in place.
• Psychosocial issues such as:
  • Financial issues
  • Childcare issues
  • Legal issues involving inheritance mostly
• Help people build on their own skill to manage their distress, even if there is nothing much you can do.

Social Support

• What practical support does your patient need and who can provide it?
• What external services are available to support your patient?

Spiritual Care

• How does the patient feel about who they are and why they are here?
• Discuss with your patient what their spiritual needs are.

• Have a framework to assessing new symptoms in them:
  • Due to the cancer
  • The treatment or
  • An unrelated cause
• And what is easily reversible?
  • Is there disease-modifying treatment we need to try to access or consider? (chemotherapy/radiotherapy/surgery)
  • What does the patient/person feel about it- what do they want?

Pain in Cancer Patients

• Pain is one of the biggest feared symptoms of cancer.
• But it is a symptom and not a diagnosis.
• It is what the person says it is.
• It can be physical, social, emotional, and/or spiritual (Total Pain).

Think about how to access any form of symptom using the acronym- EEMMA:

• Evaluation - what causes the symptom?
• Explanation - mostly a therapeutic explanation based on the information the patient wants.
• Management - how do intend to manage?
• Monitoring - by you or a colleague?
• Attention to detail.

Help people build on their own skill to manage their distress, even if there is nothing much you can do.

• The healthcare given in the last couple of months/few days before someone’s death.
• Attend to what the person might need to do:
  • Need to talk about their fears, wishes, and beliefs.
  • Need to make amends, etc.
  • Need to say thank you.
  • Need to pass on information to the next generation – discuss this with the patient and their families.

• Death is an inevitable consequence of being alive.
• Those who are dying deserve the highest standard of care.
• Good palliative care helps patients to have a “good death” which is:
  • Peaceful
  • All parties feel prepared
  • Those around are informed