1. Palliative Care: symptom Management
S. Origines- Jan 18, 2012
Physiologic Responses- terminal illness maybe caused by the disease, or by the tx of the dse
Continuity of Care
- Dse Progression: Palliative Care Death  Bereavement
Assessing symptoms:
- How is the symptom affecting life?
- What is the meaning of symptom to the patient or family?
- How does it affect physical functioning?
- What makes it better? Worse?
- How is the patient coping with the symptom?
Management:
- Pharmacologic and non-pharmacologic methods of symptom management maybe used to modify the
physiologic causes of symptoms
- Tx varies depending on the pt’s condition and impending death
Treatment priority:
A. Pain- in the final stages of illnesses such as cancer, AIDS, Heart disease, copd, renal dse, pain and other
symptoms are common
- Pain results from both dses and the modalities used to treat them
- Prevalence of pain is 50% in patients w/ cancer of all types- WHO
B. Dyspnea- a highly subjective sx, often not associated with visible signs of distress, such as tachypnea,
diaphoresis, or cyanosis
- The most common severe sx in the last days of life
- Can be a sign of impending death
1. Relief of breathlessness
o Administer prescribed oxygen therapy via nasal cannula if tolerated
o Administer prescribed low doses of opioids via oral route
 Morphine sulphate- most commonly used opioids are very effective in relieving dyspnea
o Provide air movement
2. Decrease anxiety
o Administer anxiolytic medications as prescribed
o Assist with guided imagery and breathing techniques
o Provide patient with means to call for assistance (call bell/light within reach)
3. Reduce respiratory demand
o Teach patient and family to implement energy conservation measures
o Anticipation and management of crisis situations

2. o Place needed equipment, supplies and nourishment within reach
o For home or hospice care, offer bedside commode, electric beds with head that elevates
4. Nutrition and hydration
o Anorexia
 Lacks interest in the socially important rituals of mealtime
 Progressive anorexia is an expected and natural part of the dying process
 Leads to Cachexia- severe muscle wasting
 Cachexia can lead to severe loss of energy
 Pharmacologic agents:
Increase appetite: Dexamethasone, Megestrol acetate, Dronabinol can cause weight
gain, if after 4-8 wks, there is no improvement, discontinue
 Nursing interventions:
Offer small portions of favourite foods
Cool foods may be better tolerated than hot
Offer cheese, peanut butter, mild fish, chicken or turkey
Meat may taste bitter (beef)
Schedule meals when family members can be present to provide company and
stimulation
Food preparation and meal times are important social activities in families and
communities
Assess the impact of medications (eg chemotherapy, antiretrovirals and others) that are
being used to treat underlying dse
Encourage pts to eat when effects of medications have subsided
Assess and modify environment to eliminate unpleasant odour and other factors that
cause N/V
Position pt to enhance gastric emptying: sitting, high fowlers
Assess for constipation and/or intestinal obstruction
Provide frequent mouth care
Administer and monitor effects of topical and systemic tx for oropharyngeal pain
5. Delirium- refers to the concurrent disturbance in the level of consciousness, psychomotor, behaviour,
memory, thinking, attention, and sleep-wake cycle
- In some pts, a period of agitated delirium precede death sometimes causing families to be hopeful that suddenly
active pts may be getting better
- Conclusion may be related to underlying conditions, pain or discomfort, hypoxia or dyspnea, or a full bladder or
impacted stool.
- Medications: Haloperidol- may reduce hallucinations and agitation
o Benzodiazepines (Lorezepam)- can reduce anxiety
- Nsg Int’v’n:
o Identify the underlying causes of delirium
o Acknowledge the family’s distress over its occurrence
o Teach family members how to interact and ensure safety for the patient with delirium
o Monitor the effects of medication used to treat agitation, paranoia, and fear
o Reduce environmental stimuli: avoidance of harsh lighting or very dim lighting (w/c may produce
disturbing shadows)
o Have familiar faces around the patient
o Gentle reorientation and reassurance are also helpful

3. 6. Depression- clinical depression should neither be accepted as an inevitable consequence of dying nor
confused with sadness and anticipatory grieving, which are normal reactions to the losses associated with
impending death
- Alleviate sx, psychological and emotional interventions
- Can lead to suicidal ideations- must prevent
S. Salvana
PSYCHOSOCIAL CONSIDERATIONS IN PALLIATIVE CARE
A. Communication- ability to transmit or receive information either written or oral
- Helps build a therapeutic relationship- honest and caring, trust and respect
- Elements of communication:
o Sender
o Message
o Receiver
o Feedback
o Context
a. Types
- Verbal- transmits feelings (anger and happiness)
o Involves an exchange of words, both spoken and written, between two people
- Non-verbal- more accurate in showing emotions or description of true feelings because people have less control
over it
o Touch, gestures, positions, facial expressions, vocal cues, proxemics
b. Phases
1. Introductory: pre-interaction phase nurse sets the stage for a one to one relationship by becoming acquainted
with the client
o Nurse explains relationship to the client and defines both nurse’s and client’s roles.
o Nurse determines what client expects from the relationship and what can be done for the client
o Nurse begins the assessment process and develops goals of care
2. Orientation phase  opening the relationship
o Clarifying the problem
o Structuring and formulating the contract- professional relationship
3. Working phase examining of the pt’s thoughts
o Understand and explore other problems
o Nurse will get the emotion of patient
o Client begins to trust the nurse
o The nurse elaborates on the goals of tx developed
o Perceptions of reality/death and dying, support systems are identified
o Defining what the patient believes constitutes dying well.
4. Termination phase- withdrawing medical interventions
- Preparing for impending death

4. - Smoothing the passage
- Consoling the family
- Review, explore, evaluate
c. Breaking the bad news
- Therapeutic communication techniques:
o facilitates therapeutic communication
o The ability to communicate effectively is an art that uses basic listening and communication skills
- Not an optional skill; it is an essential part of professional practice
- What is a bad news?
o Any information which adversely and seriously affects an individual’s view of his or her future
- Giving the bad news:
o Truth telling about:
 Diagnosis and prognosis
 It may not be possible for a patient to die in their place of choice
 Hoped-for financial benefits may not be forthcoming
 A respite admission may not be possible
- Why is it difficult?
o Our own inherent fears of:
 Causing pain
 Being blamed
 Our own fears of illness, rejection, being sued, death
o Our acquired fears of
 Unknown, of their reaction, our own emotions, saying “I don’t know”
- Breaking it  gentle, respectful and compassionate way
- Aim of giving the bad news to help pts remain the experts on themselves by giving the info at the rate and
depth dictated by them
- Benefits of telling the truth:
o Improve the pt and family’s ability to plan and cope
o Encourage realistic goals and autonomy
o Support the pt emotionally
o Strengthen the nurse-patient relationship
o Foster collaboration among the pt, family, physicians, nurses and other professionals
- More than 90% of Americans want to know about the info of their dx
6 steps in breaking the bad news:
1. Get the context right
2. Find out what is already known
3. Find out how much info the patient/family wants to know
4. Sharing information (aligning and educating)
5. Responding to the pt’s feelings-empathetic approach
6. Planning and following through

5. SPIKES
1. Set up- Getting started
- Create an environment conducive to effective communication; allow time and privacy
- Ensure that the right people are present (if pt wishes, have a family member present)
2. Perception- Finding out what the patient knows
- Start by establishing what the patient and family know about the pt’s health
- Questions: what do you understand about your illness?
o What did the previous doctors tell you about your illness
o When you first had sx X, what do you think it might be?
3. Invitation- finding out how much the pt wants to know
- People handle info differently
- Pt has right to decline to receive any info
- Find how the pt wants to receive info
- Explore why family doesn’t want to info pt if ever. Suggest asking patient’s opinion together.
- Questions: if this condition turns out to be something serious, do you want to know?
o Some people really don’t want to be told what is wrong with them, but would rather their families be
told instead. What do you prefer?
o Whom should I talk to about these info?
4. Knowledge- sharing the information
- Deliver the info in a sensitive but straightforward manner
- Use clear language and not abbreviations
- Stop and check pts understanding
- Do not minimize the severity of the situation. Well-intentioned efforts to soften the blow may lead to vagueness
and confusion
- Statements might include:
o Mr. Gonzales, I feel badly to have to tell you this but the growth turned out to be cancer.
- I’m sorry may be interpreted to imply that the physician/nurse is responsible for the situation
o May also be misinterpreted as pity or aloofness
- I’m sorry to have to tell you this
5. Emotions: responding to pt and family’s feelings
- Outbursts of strong emotion are an expected component of info sharing
- Pts and families respond to bad news in a variety of ways
- Listen to concerns and encourage ventilation of feelings
- Nonverbal communication may also be very helpful
- Questions: You appear to be angry. Can you tell me what you are feeling?
o Tell me more about how you are feeling about what I just said?
o What worries you most?
o What does this news mean to you?
o Is there anyone you would like for me to call?
o I’ll help you tell your son
6. Summary: planning, follow-up
- Summarize the discussion and have person begin to think about a plan of care
- Foster realistic hope
- Clear definite plan for the immediate future
- Discuss potential sources of emotional and practical support
- Establish a time for a follow-up appointment

6. 7. Strategy: Offer availability
- Future meeting
- Need to ask more questions
- Chance to meet with family
- When language is a barrier
o Verify that translators will be comfortable and sufficiently skilled in translating the news you are about
to give
o Avoid using family members as primary translators because it confuses their role, frequently
compromises the therapeutic quality of the interview and may compromise some pt’s desires for
confidentiality
Summary of tasks:
SPI- preparing to break bad news (SPI)
K- Breaking the bad news
ES- help pt deal with the bad news