Palliative Care Nursing

A Guide to Practice

O'Connor Margaret, Aranda Sanchia

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315358475
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Written by experienced authorities from around the world giving a wider international perspective on palliative nursing, this substantially expanded new edition has been specifically adapted to reflect working practices within the NHS. All nurses especially those that are new to palliative care, and those working in other areas of health where palliative skills are required, will find this essential reading.

Sanchia Aranda

Sanchia Aranda is professor and director of cancer nursing research at Peter MacCallum Cancer Institute, Melbourne (Victoria, Australia). She has worked in cancer care since 1979, predominantly in the tertiary sector since 1990. Her research interests include cancer and palliative nursing in both inpatient and community settings, especially in the area of supportive care. Her research, both quantitative and qualitative, concentrates on implementing evidence into clinical practice, especially in improving the delivery of health services and the outcomes for people with cancer and their families. Current studies include workforce planning in breast care, the support needs of women with advanced cancer, symptom interventions in pain and fatigue, prevention of oral mucositis, and care of people suffering bodily decay.

Chapter 1

Framing Palliative Care

Sanchia Aranda

The purpose of this book is to disseminate knowledge of palliative-care nursing to improve the care of people at the end of their lives, and to provide care and assistance to their families, friends, and carers. It is important that knowledge of palliative care is available to nurses who care for dying people, regardless of the health-care setting or the diagnosis. Because dying people can be found in almost any setting, palliative care is increasingly a core component of all health-care roles.

Palliative care occurs at three levels (Finlay & Jones 1995):

◗  the palliative approach;

◗  specialist interventions; and

◗  specialist palliative care.

The palliative approach consists of a core set of knowledge and skills, and can be used by all health professionals who are involved in caring for people with life-threatening or terminal illnesses. At this level, all nurses can undertake basic symptom assessment and management, understand the experiences of dying people and their families, engage in communication regarding individual needs and experiences, and consult with specialist palliative-care practitioners if the needs of these people are outside the nurses’ expertise.

Specialist interventions by practitioners from disciplines outside palliative care are sometimes required to assist in the management of difficult nursing problems. Examples include the involvement of a wound nurse in the care of a malignant wound or the involvement of a radiotherapy nurse in palliative radiotherapy.

Specialist palliative care is provided by practitioners who have specialist qualifications and experience in the care of dying people and their families. These practitioners might work in specialist community palliative-care services, in palliative consulting services in an acute hospital, or in a hospice. The involvement of such specialist services and practitioners is most relevant for patients with complex and difficult symptoms or care needs. Such specialist services might be involved in an advisory capacity, or can assume primary care of the patient.

This book provides a core set of knowledge that can be applied at each of these three levels of practice, but the focus of the book is to assist all nurses to incorporate palliative care into their work, on the premise that all nurses require access to information that will support their care of dying people and their families. The book presents palliative care as the expert, holistic, and interdisciplinary care that is offered to dying people, regardless of diagnosis or care setting. It is a continuum of practice from a generalised approach to a specialist discipline.

Even though one of the tenets of palliative care is the promotion of equitable access, there are still considerable difficulties with access to palliative care in many communities and in many settings of care, especially for people with non-cancer diagnoses. In part, this is caused by the reluctance of some health professionals to involve specialist palliative-care services in the care of people who have palliative needs. In addition, there is still some ignorance in the community about the care of people facing the end of life. Public testimonials in the media about unnecessary suffering in dying are evidence that many people still do not have ready access to expert palliative care. Despite efforts to the contrary, palliative care continues to be represented in the media in the context of discussions about the active ending of life.

The artificial separation of curative care and palliative care means that people are sometimes reluctant to recommend or receive palliative care because it infers an acceptance of inevitable death. However, there is now an increasing recognition that many people actively seek life-prolonging therapy while simultaneously requiring palliative care. In the future, especially with an ageing population, palliative care will be more closely integrated into the acute care of people with chronic life-limiting illness. Nurses who work with chronic illness will therefore require an increasing level of palliative-care knowledge. The goal of this book is to transcend settings of care and diagnosis in setting out a knowledge base that is applicable to all.

In facing the challenges of promoting the best care for people at the end of life, and support for those who are significant to them, nurses will find this approach to palliative care useful in understanding need and in promoting palliative-care practices in all environments.

Alan Pearson

Professor Alan Pearson is head of nursing in the School of Nursing and Midwifery, La Trobe University, Melbourne (Victoria, Australia). Alan has extensive experience in nursing practice, nursing research, and academic nursing. Having qualified as a registered nurse in 1969, he has practised in a range of nursing fields in the United Kingdom, Papua New Guinea, and Australia. He has been an active researcher since 1981 and has conducted a large number of research projects in the fields of aged care, nursing history, and organ donation. Alan was instrumental in establishing the Joanna Briggs Institute for Evidence Based Nursing (of which he is currently the director) and is the foundation director of the newly established Australian Centre for Evidence Based Residential Aged Care. He has played a leading role in promoting research of evidence-based practice in Australia, New Zealand, and Hong Kong. Alan is editor of the International Journal of Nursing Practice and has published 20 books and numerous journal articles. He is active in developing and promoting nursing at the state, national, and international levels.

Chapter 2

Evidence-Based Practice in Palliative Care

Alan Pearson

Introduction

In the industrialised world, all areas of the health-care system are facing increasing demands and an escalation in costs. Governments and health-care professionals have responded to this in a variety of ways. Some responses focus on cost-cutting—by rationing services, by introducing measures to increase productivity, and by imposing cost-shifting exercises. This has involved serious ethical discussions of what can be afforded and what cannot, and the development of processes to provide essential health services to those who most need it. Some responses promote a ‘user-pays’ approach, and others simply blame others!

Another response is that of evidence-based practice (EBP). The emergence of EBP has led, in most Western countries, to a focus on best practice, based on the best available evidence.

This chapter provides an overview of the development of EBP, considers the processes of EBP, and discusses its limitations in palliative care. The view presented here is that clinical performance and professional judgment in the ‘information age’ must increasingly be based on exposure to summarised evidence and that, in the not-too-distant future, practice that is not based on a consideration of the evidence will be difficult to justify.

EBP: What is it?

Simply defined, EBP is a combination of individual clinical professional expertise with the best available external evidence to produce practice that is most likely to lead to a positive outcome for the person receiving care.

Although medicine and nursing are the health-care occupations that are most advanced in the EBP movement, the ideas and arguments are common to all professionals who work in health care. Sackett et al. (1996) have contended that evidence-based medicine (EBM) had its philosophical origins in the mid nineteenth century in Paris. They defined it as being ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (p. 71).

‘Professional judgment in the ‘information age’ must increasingly be based on exposure to summarised evidence … practice that is not based on a consideration of the evidence will be difficult to justify.’

The establishment of the Cochrane Collaboration stemmed from the work of A.L. Cochrane. He drew attention to the lack of information about the effects of health care, with particular reference to medicine, and suggested (Cochrane 1979) that it is:

… surely a great criticism of our profession that we have not organised a critical summary by specialty or sub-specialty adapted periodically of all relevant randomised controlled trials.

Cochrane argued that, because resources for health care are limited, they should be used effectively to provide care that has been shown, in valid evaluations, to result in desirable outcomes. He emphasised the importance of randomised controlled trials in providing reliable information on the effectiveness of medical interventions.

The development of EBM has been rapid—led by Professor David Sackett, formerly of McMaster University in Canada, and now of the University of Oxford, England. EBM has been defined by Sackett and colleagues (1996, p. 71) as:

The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Sackett and Rosenberg (1995) have suggested that EBM is concerned with five linked ideas:

◗ that clinical and other health-care decisions should be based on the best patient-based, population-based, and laboratory-based evidence;

◗ that the nature and source of the evidence to be sought depends on the particular clinical question;

◗ that the identification of the best available evidence requires the application of epidemiological, economic, and biostatistical principles, together with a consideration of the relevant pathophysiology in the context of personal experience;

◗ that this identification and appraisal of the evidence must be acted upon; and

◗ that there should be continuous evaluation of performance.

‘EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.’

The Cochrane Collaboration provides systematic reviews of randomised controlled trials with respect to specific medical conditions, specific client groups, and specific interventions by health professionals. Such a systematic review of any given topic involves:

◗ determining the objectives and eligibility criteria for including trials;

◗ identifying studies that are likely to meet the eligibility criteria;

◗ tabulating the characteristics of, and assessing the methodological quality of, each study identified;

◗ excluding studies that do not meet the eligibility criteria;

◗ compiling the most complete set of data feasible, involving the investigators if possible;

◗ analysing the results of eligible studies, using a meta-analysis or statistical synthesis of data if appropriate and possible;

◗ performing sensitivity analyses if appropriate and possible; and

◗ preparing a structured report of the review that states the aims of the review, describes the materials and methods used, and reports the results.

The Cochrane Collaboration caters for other interests, including nonmedical groups. In the health-care field, it assists certain categories of health-service users, different groups of health professionals, various health-care settings, and certain classes of intervention. The involvement of nurses is, however, just beginning to occur in most Western countries.

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Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Acknowledgements
• Chapter 1 Framing Palliative Care
• Chapter 2 Evidence-Based Practice in Palliative Care
• Chapter 3 Communication Skills in Palliative Care
• Chapter 4 Occupational Stress in Palliative Care
• Chapter 5 Ethical Decision-making
• Chapter 6 Spiritual Care
• Chapter 7 A Framework for Symptom Assessment
• Chapter 8 Pain Management
• Chapter 9 Breathlessness
• Chapter 10 Fatigue
• Chapter 11 Constipation
• Chapter 12 Nausea and Vomiting
• Chapter 13 Nutrition and Hydration
• Chapter 14 Malignant Wounds
• Chapter 15 Confusion and Terminal Restlessness
• Chapter 16 Psychological and Existential Distress
• Chapter 17 Sexuality and Body Image
• Chapter 18 Complementary Therapies
• Chapter 19 Working with Families
• Chapter 20 Bereavement
• Chapter 21 Palliative Care in Chronic Illness
• Chapter 22 Ageing, Dementia, and Palliative Care
• Chapter 23 Caring for Dying People in Critical Care
• Chapter 24 Paediatric Palliative Care
• References
• Index