Palliative

and
End-of-Life
Care
Presented by: Jon Kenneth R. Lorico, RN
 Objectives
After the discussion the students will be able to:
1. Define Palliative and Hospice Care
2. Differentiate the difference between Palliative and
Hospice Care
3. Understand the underlying factors that
4. Know the importance of Palliative and Hospice Care
5. Determine the nursing responsibilities in caring
terminally ill patients
Palliative Care
Latin: Palliare, which means to cloak
.
Palliative care is an interdisciplinary
medical caregiving approach aimed at
optimizing quality of life and mitigating
suffering among people with serious,
complex, and often terminal illnesses.

-Offered alongside curative or other

treatments
.
 Palliative Care
- an approach that improves the
quality of life of patients and
their families facing the
problems associated with 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, psychosocial, and
spiritual.
 Findings
Ratio
56.8 million people need of
palliative care

98% children needing palliative

care live in low and middle
countries

Worldwide: 14% received

palliative care.
Scope Illnesses
• Cancer
Palliative care may be • Blood and bone
offered to people of marrow disorders
requiring stem cell
any age who have a transplant
serious or life- • Heart disease
threatening illness. It • Cystic fibrosis
can help adults and • Dementia
• End-stage liver
children living with disease
illnesses • Kidney failure
• Lung disease
• Parkinson's disease
• Stroke
Symptoms that may be improved by
palliative care

● Pain
● Nausea or vomiting
● Anxiety or nervousness
● Depression or sadness
● Constipation
● Difficulty breathing
● Anorexia
● Fatigue
● Trouble sleeping
Palliative Care
Team
 Doctors
 Nurses and nurse
practitioners
 Physician assistants
 Registered dietitians
 Social workers
 Psychologists
 Massage therapists
 Chaplains
Palliative Care
Team
 Doctors
 Nurses and nurse
practitioners
 Physician assistants
 Registered dietitians
 Social workers
 Psychologists
 Massage therapists
 Chaplains
 Stages of Palliative Care
Stabl
01 e 02 Unstable

Deterioratin
Terminal Bereavement
03 g 04 05
Stage 1: Stable
Developing & Implementing the Care Plan

Palliative care can start at any phase but is commonly started as soon as an individual
receives a prognosis of a life-limiting illness.

Initial plan:
 Current and future treatment plan
 Evolution of illness
 Medication and symptom relief
 Care Preferences
Stage 2: Unstable
Adjusting the Care Plan & Preparing Emotionally

If an individual’s illness is displaying worsening symptoms or new medical

problems arise, the specialist palliative care team will urgently revisit the care
plan and adjust (or add) any palliative care services to ensure that their client
continues to be comfortable throughout their care journey.
Stage 3: Deteriorating
Shifting to End-Of-Life-Care

If an individual’s overall health and body functions continue to gradually

worsen, with severe medical conditions continuing to develop, the palliative
care team will start to shift from palliative care into the end of life care with
periodic assessments of the care plan.
Stage 4: Terminal
Symptom Management, Emotional & Spiritual Care

When an individual is experiencing a terminal illness this means that they are nearing the
end of their life and may only have days left. During this stage, the primary focus is to
ensure that the affected individual continues to be as comfortable as possible.

Physical Symptoms
 Bedridden
 Mobility issues
 Loss of appetite
 Difficulty of swallowing
Stage 5: Bereavement
Support for Family Members, Loved Ones & Carers

In the final stage, the individual with the life-limiting illness has passed on. A loved one’s
death can take an incredible toll on family members, carers, and the rest of the palliative
care team.

Bereavement Service:
 Emotional Support
 Spiritual Support
 Psychosocial Support
Interventions
Emotional and Social
Physical Problems
Problems
• Medicine • Counseling
• Nutritional guidance • Support groups
• Physical therapy • Family meetings
• Occupational therapy • Referrals to mental health
• Integrative therapies providers

Practical Problems Spiritual Problems

• Explain complex medical forms or help A palliative care team may help
families understand treatment choices patients and families explore their
• Provide or refer families to financial
counseling
beliefs and values so they can move
• Help connect you to resources for toward acceptance and peace.
transportation or housing
BENEFI
TS Physical
Relieve Pain
Manage Symptoms
Mitigate Discomfort

Psychosocial
Provide Medical and Social Support
Fulfil goals and desire

Spiritual
Empowerment
Finding purpose and closure
Hospice
Care
HOSPICE
Latin: hospitum, means hospitality or place of rest
CARE
Hospice care focuses on the care, comfort, and quality of
life of a person with a serious illness who is approaching
the end of life.

Hospice is provided for a person with a terminal illness

whose doctor believes he or she has six months or less to
live if the illness runs its natural course.

GOAL: Support the highest quality of life possible for whatever

time remains.
History
1065 – originated in Malta
Early 14th century – opened the first hospice in
Rhodes

United Kingdom – has widely developed.

London (1982) – offered 35 beds (tuberculosis)

Hospice – primarily with tuberculosis and cancer.

Dame Cicely Saunders – first modern hospice care

Scope
Person: 6 months or less to live

Usual Diseases:

1. Cancer

2. Heart Diseases

3. Dementia

4. Kidney Failure

5. COPD
 Hospice Care
Responsibility
2 Types of setting - Regular visits
1. Home (most hospice care) - Readily available
2. Health Facility - Health Education

Team with special

skills
• Nurses
• Doctors
• Social Workers
• Spiritual Advisors
• Trained Volunteers
• Bereavement Counselors
 Level of Care
Range of services receive in
Routine Home Care patient’s home

Continuous Home
Higher level of Nursing Care
Care
Admitted to an Inpatient
General Inpatient Facility

Lower caregiver stress Respite Care

 Services

Symptom Control Family Meetings

Home Care Coordination of

Care

Spiritual Care Respite Care

Bereavement Care
Services:
❏Regular Visits
❏Medication for symptom control, including pain relief
❏Medical equipment Physical and occupational therapy*
❏Speech-language pathology services*
❏Dietary counseling*
❏Any other Medicare-covered services
❏Short-term inpatient care
❏Short-term respite care for family caregivers
❏Grief and loss counseling for the patient
 Hospice Care
Advantage Disadvantage
1. Comprehensive, 1. Denial of diagnostic test
interdisciplinary care from a
team of professionals.
2. Care is available 24 hours a 2. Hospitalization is
day Discouraged

3. Reduction of out-of-pocket 3. Participation in

expenses experimental treatment is no
allowed
4. Avoiding unwanted
hospitalization
 Challenges
Society Healthcare
• Constrained • Lack of training
country • Low interest
• Lack of public • Decrease number of
awareness personnel
• Unwillingness to refer
Government
• Lack of political
Service
• Trained and available
will
volunteers
• No Hospice • Administrative support
funding • Procurement
• Training
• Attachment to patients
 Question Palliative Care Hospice

Who can be treated? Anyone with a serious illness Anyone with a serious illness who doctors think has only a short
time to live, often less than 6 months

Will my symptoms be relieved? Yes, as much as possible Yes, as much as possible

Can I continue to receive treatments to cure my illness? Yes, if you wish No, only symptom relief will be provided

Will Medicare pay? It depends on your benefits and treatment plan Yes, it pays for some hospice charges

Does private insurance pay? It depends on the plan It depends on the plan

How long will I be cared for? This depends on what care you need and your insurance plan As long as you meet the hospice's criteria of an illness with a life
expectancy of months, not years

Where will I receive this care? • Home • Home

• Assisted living facility • Assisted living facility
• Nursing home • Nursing home
• Hospital • Hospice facility
• Hospital
Anorexia-
Cachexia
Syndrome
The major cause of morbidity
and mortality in cancer,
HIV diseases, and other
long-term illnesses.
 Definition
● Anorexia is defined as a loss of normal appetite.

● Cachexia is the associated nutritional deficiencies and

weight loss.

● The anorexia/cachexia syndrome, characterized by:

1. progressive nutritional changes

2. Weakness

3. Wasting (loss 10% of premorbid weight)

Introduction
Anorexia is a decrease or loss of appetite
● Can be a symptom of a terminal disease process,
such as cancer & end-stage CHF
● Prevalence of anorexia is 66% in patients with
advanced cancer.

● Anorexia may occur in isolation or as part of

anorexia-cachexia syndrome
● Management involves evaluating for reversible
causes
Introduction
● Anorexia is a decrease or loss of appetite
● Can be a symptom of a terminal disease process,
such as cancer & end-stage CHF
● Prevalence of anorexia is 66% in patients with
advanced cancer.
● Anorexia may occur in isolation or as part of
anorexia-cachexia syndrome
● Management involves evaluating for reversible
causes
Causes
Anorexia Medication side effects: GI causes
Constipation, fecal Impaction
Nausea, vomiting
GERD, gastritis, gastro paresis
Malabsorption: Pancreatic ca, diarrhea

Dysphagia
Depression, anxiety
Oral problems: dry mouth, candidiasis, stomatitis, dental
pain, ulcers, poorly fitting dentures
Causes
Metabolic disorders
Thyroid problems
Diabetes
Adrenal insufficiency

Altered taste and smell Odors (e.g.

certain smells of food)
Generalized weakness, lethargy
Introduction
Cachexia A wasting syndrome characterized by
disproportionate loss of skeletal muscle over fat
● Primary cause of death in about 20% of all patients
with cancer

● Often occurs concomitantly with anorexia, as it is

caused by the same factors that cause anorexia
● Multi-factorial etiology is not clearly understood,
but chronic inflammation is the core mechanism
● Tends to be very distressing for patients & families
Markers:
Cachexia
Primary Cachexia/Anorexia
CRP Albumin

-increasing levels of CRP =

chronic inflammation

Hemoglobin Lymphocyte
Anorexia-Cachexia from Cancer
Distinct from other secondary causes of anorexia-cachexia
- Includes correctable problems, including pain, infection, emotional
disorder, obstruction, constipation
Not reversible with aggressive feeding / increased calories –
- Enteral and parenteral nutrition offer no significant benefits & do not
improve survival or comfort
Weight loss correlates with cytotoxic effects of & poor tumor response to
chemotherapy
Often present at diagnosis of certain cancers
- Non-small cell lung, upper GI, pancreatic
Concomitant presence of anorexia carries a poorer prognosis
Management
Nutritional supplements
– Oral protein shakes, protein powders
*Take in ADDITION to food not instead of
meals
– Calorie dense supplement (Benecalorie)
* Add to pureed foods, adds calories, no
nutrition

Appetite stimulants
1. Megesterol acetate
2. Marinol
3. Dexamethasone
Management
Megesterol acetate (Megace)
Improves appetite and weight gain –
Most of the weight gain is from fat not lean muscle
Best absorbed when taken with a high-fat meal
Start with 400mg/day. If appetite is not better in 2 weeks, then
increase to 600-800mg/day.
Takes a few weeks to take effect but longer duration of a benefit
than steroids

Side effects: Increase the risk of venous thromboembolism, fluid

retention
Contradictions: history of DVT, thrombophlebitis
Do not discontinue abruptly if used for more than 3 weeks
(adrenal suppression); taper off slowly
Management
Cannabinoids Marinol (tetrahydrocannabinol,
THC)
Improves weight gain and appetite in patients with
AIDs & cancer
Start with small dose and up titrate to effect and
tolerability 7.5mg to 15mg /day
Example dosing: Marinol 2.5mg po TID one hour after
meals

Adverse side effects: anxiety, somnolence,

neurotoxicity
Management Corticosteroids
Stimulates appetite short-term
Dexamethasone preferred over other corticosteroids for
appetite stimulation due to its relative lack of
mineralocorticoid effect
Rapid effect, long half life but effect limited 2-6 weeks Doses
of 2-16 mg/day dexamethasone
Side effects: fluid retention, increased infection risk, gastritis,
insomnia, proximal muscle wasting with prolonged
treatment, steroid psychosis
Consider 1 week’s trial
– If no improvement, then discontinue
– If helps, then reduce to the lowest effective dose.
– Reassess need frequently; discontinue when no longer
effective
Management
Other Agents:

1. Psychotropics – Mirtazapine,
atypical antipsychotic

2. Fish Oil

3. Thalidomide
Correctable Causes and Management
Emotional disorders
– Anxiolytics, antidepressants, counseling for patients
& families Eating issues
– Dietitian referral, multivitamin, zinc / flavoring
food with spices (for disturbed sense of smell or taste)
Oral problems
– Oral moisturizers, antifungal meds to treat thrush (if
present), change meds that may cause dry mouth
Swallowing difficulties
– Esophageal dilation, antifungal med for thrush (if
present)
Correctable Causes and Management
Stomach issues
– GERD- proton pump inhibitors
– Gastric stimulants (for early satiety), treat n/v
Bowel issues
– Treat constipation / obstruction
Malabsorption
– Pancreatic enzymes
Fatigue
– anxiolytics, exercise protocol, sleep protocol
Motivation issues
– methylphenidate, exercise
Pain
– appropriate analgesics, nerve blocks, counseling
 Remember
!
Don’t focus on appetite and weight
– Let the patient guide new eating habits
– Liberalize dietary restrictions
– Maintain muscle function
Intervene early in disease
– Nutritional supplements
– Exercise
– Consider medical therapies
Address patient and families fears
– Identify alternative non-food methods of
expressing love, caring
 Nursing Responsibilities
1. Eliciting the patient’s goals for care

2. Listening to the patient and their family members

3. Communicating with members of the interdisciplinary team and

advocating for the patient’s wishes

4. Managing end-of-life symptoms

5. Encouraging reminiscing

6. Facilitating participating in religious rituals and spiritual practices

7. Making referrals to chaplains, clergy, and other spiritual support

 Nursing Responsibilities
Management of common symptoms
• Pain • Depression
• Dyspnea • Anxiety
• Cough • Cognitive changes
• Anorexia and • Fatigue
cachexia • Pressure injuries
• Constipation • Seizures
• Diarrhea • Sleep disturbances
• Nausea and vomiting
 Nursing Responsibilities
Pain
Assessment (Objective and Subjective)
Pharmacologic Intervention
Non-pharmacologic Interventions
Evaluate

Dyspnea
Assessment (Objective and Subjective)
Pharmacologic Intervention
Non-pharmacologic Interventions
Evaluate
 Nursing Responsibilities
Anorexia and Cachexia
Assessment (Reversible Causes)
Food Preference (High Protein)
Medication
Education
 Nursing Responsibilities
Depression
Interdisciplinary Assessment
Pharmacologic Interventions
Nonpharmacologic Interventions
1. Promoting and facilitating as much autonomy and control as possible
2. Reminiscing and life review to focus on life accomplishments and to promote closure and
resolution of life events. for an image of reminiscing with pictures.
3. Grief counseling to assist patients and families in dealing with loss
4. Assisting the patient to draw on previous sources of strength, such as faith, religious rituals,
and spirituality
5. Referring for cognitive behavioral techniques to assist with reframing negative thoughts into
positive thoughts
6. Teaching relaxation techniques
7. Providing ongoing emotional support and “being present”
8. Facilitating spiritual support
 Nursing Responsibilities
Anxiety
Assessment
Pharmacologic Interventions
Nonpharmacologic Interventions
1. Promoting the use of relaxation and guided imagery techniques, such as breathing exercises,
progressive muscle relaxation, and the use of audiotapes
2. Referring for psychiatric counseling for those unable to cope with the experience of their
illness
3. Facilitating spiritual support by contacting chaplains and clergy
4. Acknowledging patient fears and using open-ended questions and active listening with
therapeutic communication
5. Identifying effective coping strategies the patient has used in the past, as well as teaching new
coping skills such as as relaxation and guided imagery techniques
6. Providing concrete information to eliminate fear of the unknown
7. Encouraging the use of a stress diary that helps the patient understand the relationship between
situations, thoughts, and feelings
Thank You