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This review aims to identify the most appropriate and cost-effective models of service delivery and level of provision for palliative care services. This includes the role of nurses in hospitals and the community, and the care of dying patients in acute hospitals. Ten key research questions were identified within this aim including the current need for and provision of services, proposed alternative models of provision, appropriate skill mix in nursing, the relationship between alternative models of care and patient satisfaction, carer satisfaction and patient's quality of life, and the impact of alternative models on other services. In this study a comprehensive review of literatures from the UK, North America, Europe, and Australia was conducted. Over 2,000 documents were identified, of which 673 were deemed to be relevant. Data extracted from these literatures were collated and synthesized in the sections of this study, along with tables of summary data derived from relevant papers.

This chapter discusses symptom control in care of the dying. It begins by discussing how the Liverpool Care Pathway for the Dying Patient (LCP) can influence symptom control, and then determines the commonest symptoms in a dying patient. The chapter looks at managing various ailments of a dying patient, including pain, agitation, and nausea and vomiting. It then determines the different factors doctors need to consider when taking care of a dying patient, such as the application of drugs, providing comfort in the last hours or days of a patient's life, and even management of skin.

This chapter examines the role of spirituality in caring for chronically ill and dying patients. It discusses the issues of living with the dying, the influence of science and technology in the changes in the conditions of dying people, and hospice and palliative care sectors' recognition of the importance of the spiritual dimension in the care of dying patients. The chapter also reviews the results of studies and research concerning the relation between health and spirituality, highlighting the importance of spirituality in patients' lives.

This chapter discusses symptom control in care of the dying. It is divided into three sections, each of which is written by a single author. The first section, written by Paul Glare, looks at the influence of the Liverpool Care Pathway for the Dying Patient (LCP) on symptom control, and the most common symptoms found in a dying patient. Pain management and managing agitation in dying patients are also studied. Andrew Dickman is the author of the second section, which focuses on the use of syringe drivers and managing respiratory tract secretions and dyspnoea in dying patients. Finally, the third section is prepared by Margaret Goodman, and it studies bowel care, micturition difficulties, mouth care, and mobility or pressure area care. Deciding when to stop administering nursing interventions is also discussed.

This chapter discusses a proposal to raise awareness of the communication skills that are necessary for promoting the principles of high-quality care, which is the aim of the Liverpool Care Pathway for the Dying Patient (LCP). It also addresses the communication skills needed to handle the many difficult situations that frequently arise when caring for dying patients. The various blocking tactics that may hinder communication are also examined.

This chapter discusses palliative care issues during the final 48 hours of the patient. This so-called terminal phase or active dying is characterized by a series of changes that affect the dying person, the family, and the clinicians. The chapter explains the prediction, the symptoms, and the role of the family in active dying. It also provides a clinician checklist for actively dying patients.

This chapter begins with a discussion of the changing aims of medicine, from the originally simple purpose of making a diagnosis, followed by attempting a cure and if that were not possible, then trying to palliate the consequences, into broader and more humanistic objectives. The first of these modern objectives is the increasing investment into prevention and earlier detection of disease, reflecting the current view that earlier intervention with many diseases may result in a better chance of disease eradication. The discussion then covers the factors determining symptom perception and the success of palliation, care of dying patients; models of palliative care; palliative medicine as a specialty; implementing a comprehensive supportive care network; who could benefit from comprehensive supportive care; constituents of a supportive care network; the relationship between supportive care and palliative care; end of life care; and assisted dying and euthanasia.

This chapter discusses in detail the Liverpool Care Pathway for the Dying Patient (LCP), which was briefly discussed in the introductory chapter. It looks at the LCP Continuous Quality Improvement Programme, which is one of the key programmes found within the Marie Curie Palliative Care Institute Liverpool (MCPCIL) portfolio. It discusses the format and outline of the LCP and introduces the concepts of variance reporting, which tells the ‘story’ of the patient's journey and current condition, and organizational governance. It then moves on to the innovation and change model, the recognition and diagnosis of dying, and the MDT assessment. The latter half of the chapter focuses on the different steps taken in order to complete the LCP.

This chapter examines the legal context within which decisions about the end of life are made. It argues that an ethical approach to end-of-life care must be centred on the dying person and that finding ways to ensure that this person’s voice is heard must be core to the development of legal frameworks. In this respect, the law has, to date, been inadequate. It explores the ways decisions about the end of life are made in Ireland and identifies likely changes, including an increased formalisation of dying. Drawing on experiences from the United States and the United Kingdom, it develops arguments regarding the most appropriate decision-making structures within which to consider difficult questions around end-of-life care.

This chapter addresses the needs of patients dying from progressive non-malignant diseases and those of patients living with non-malignant diseases in the acute hospital setting, and discusses the challenges that these patients present. Three perspectives run as vertical threads through the chapter, that of the patient and the family, that of non-specialist staff, and that of specialist palliative care staff. The study is limited by the lack of formal trials of palliative care for patients with non-malignant disease in the acute hospital setting. Thus, the authors also reflect on their experiences as members of an interdisciplinary hospital palliative care team. Where necessary, they have made considered extrapolations from the literature on palliative care for cancer patients in the acute hospital and other settings.

Maintaining a normal life for as long as possible, being in familiar surroundings cared for by a relative, and supported by health professionals well known to them, have all been found to be aspects of home care services valued by patients and carers. Home is, therefore, both the place where most people spend most of their last months of life and the place where most would want to die, although many do not achieve this. The primary location of palliative care therefore remains in the community, under the care of the patient's GP and district nurse. This chapter explores the quality of palliative care provided in the community in the UK, the relationship between primary care services and specialist palliative care services, and suggests a community view of the extension of specialist palliative care services to non-cancer patients. It begins, however, with an overview of the provision of health and social care in the community in the UK, with particular emphasis on recent changes which have impacted on palliative care.

This chapter presents a case study to illustrate the desired skills, attitudes, and knowledge required to integrate the needs of the dying patient and their family when providing care. It considers some questions such as: What is required to understand better and treat Mrs S. B. 's current situation (Mrs S. B. is a seventy-four-year-old woman with non-small-cell lung cancer and liver metastases). What possible reasons might there be for Mrs S. B.'s decline? What resources need to be in place to enable Mrs S. B. to remain at home for her last days and hours? How to assess the patient's and family's insight and understanding? What will dying look like? What needs to happen at the time of death?

Caring for a dying patient requires clinical expertise and humanity of the medical team. There is a sense of urgency, power, and poignancy in accompanying the people in their last days of life that has a great impact on the boundaries of care. The duties of the clinician in this phase usually extend beyond the clinical domain, and these non-clinical aspects of end-of-life care challenge most physicians. This chapter discusses end-of-life care, with emphasis on the practical issues associated with dying, such as planning for the preferred death and establishing good communication within the grieving family. It also examines the medical aspects of end-of-life care. Discussed are the proper methods of approaching and caring for a comatose and dying patient, medication reassessment and review, symptom management of specific issues in end-of-life care, and crisis management.

This chapter introduces some theoretical underpinning for the view of interprofessional education in palliative care; discusses the meaning of care in an interprofessional context; suggests ways of developing a shared vision of care; and discusses ways in which one can learn about the delivery of interprofessional care. It also argues that professional caregivers must be responsive to the range of needs of the dying patient and their family. In doing so, they will perform a variety of work, some clearly determined by their scope of practice, but much determined by the unique needs of the patient at any given time. The discussion also suggests that the patient's needs are to be discovered in the patient narrative and ideally lead to a shared vision of care.

This chapter sets out the context and complexity of family carer experiences and needs when providing support to older family members in the palliative care phase. The roles, tasks, and experiences of family carers are set within a contemporary ageing demographic context. The chapter draws on assessment and intervention evidence to identify family carer benefits, and highlights effective communication as key to practice interventions that enable professionals to acknowledge and address family carer needs and their pivotal relationship with palliative and dying patients. We argue that despite family carer policy developments in many countries, the support provided to older patients remains under-recognised and under-recompensed.

This chapter explores the concept of learning from your experience in clinical practice, and is designed to help you to use reflection as a means of learning both to make decisions in practice and to learn from the decisions that you have made. The use and value of reflective practice will be explored in many of the chapters to come; it is considered to be essential in the development of decision-making skills as a student nurse, and for your ongoing personal and professional development as a qualified registered nurse. Learning from experience is often referred to as ‘experiential learning’ and one of its key skills is reflection. In other words, reflection is the key to helping you to use experiences as a student and a person in order to learn from them. This chapter will provide some definitions of reflection and will introduce some commonly used frameworks or models that can help you to develop the underpinning skills required if you are to be a reflective practitioner. There are also activities for you to complete, so that you can begin to use a range of different frameworks that are appropriate to different situations. To place reflection in the context of your learning to become a nurse and therefore to achieve the appropriate competencies, the Nursing and Midwifery Council (NMC) states that: We can see from this statement that there appear to be some key assumptions and activities that are seen as working together, including reflection, and these will be explored particularly in this chapter. Reflection on practice, and subsequently for learning from this practice, will be two of the most important aspects that will be addressed. To begin with, however, we need to consider some of the underlying principles in which reflection and reflective practice are embedded. Learning from our experiences means that we can either use what we have learned to develop and to enhance future experiences, or alternatively that we can learn from any mistakes that we may have made in the anticipation that we will not make the same ones again.