Palliative care is not only to address the holistic needs of the patient rather than, it implies patient centered care at the terminal stage of the disease process. Sometimes, obtaining this goal becomes more difficult, when the patient is suffering from complex physiological phenomena of human being that is "aging". Together with this multiple chronic illness is also another important aspect from the care point of view. However, this is the responsibility of the nurse to look upon all these issues in order to satisfy the patient's needs. In this paper, physical and spiritual needs of a patient is being addressed with the interventions that can be done looking upon the patient's condition at the terminal stage of his illness.
Loscalzo, (2008) states “Prevention and relief of suffering through the meticulous management of symptoms from the early, through the final stages of an illness” ( Admin, 2013 , Institute of Medicine (IOM) Report).
Palliative care affirms life without distress and helps to die peacefully. Death is an unavoidable phenomena of human life. It becomes more complex when illness is accompanied by the more complex age related process called 'aging' described as "a persistent decline in the agespecific fitness components of an organism due to internal physiological degeneration" (Rose, 1991; Flatt, 2012). Yet, providing palliative care in such tough times has undoubtedly become harder. Because the goal of the palliation is not only to provide care holistically, that includes physical, emotional, spiritual, sexual, social and psychological rather, it is the continuum of care that is directed towards the patient and the family centered care that aims to improve the quality of life by relieving, avoiding and treating the suffering irrespective to the stage of the disease and need for other therapies by facilitating patients right to access information and choice of treatment ( Clinical Practice Guidelines for Quality Palliative Care, 2009 ). Therefore, together with the patient facing terminal illness, it embraces the people close to them that is family, friends, relatives, etc.
A case scenario pertinent to provide palliative care for an elderly patient was encountered by the author during her clinical rotation. A 85 year old male, was presented with the complaint of abdominal pain and distention i.e. Constipation, heartburn, generalized colicky pain non radiating and mild in intensity, vomiting, fever. His symptoms developed a day before the appointment with the neurologist as he is the known case of Chronic Kidney Disease (CKD). Along with this, the patient has the history of Ischemic Heart Disease (IHD) for which, Percutaneous Coronary Intervention (PCI) was done in 2007 and Hypertension (HTN). On the day of appointment looking on to the patient's condition and his worsening symptoms, he was asked for an admission to the hospital. The patient was diagnosed with Acute Kidney Injury (AKI) on CKD as his creatinine levels were highly elevated i.e. 8.2 μmol/l. Else, his lab reports revealed an electrolyte imbalance due to the decrease potassium levels, i.e. 3.1mmoI/L, urinary tract infection, uroseptic shock because of the Pseudomonas found in the urine culture report, metabolic acidosis and hydronephrosis for which, bilateral Percutaneous Nephrostomy (PCN) was done after the admission. Adding in to his stress, the patient was on complete bed rest from last two months because he fell in washroom while performing ritual ablution (wadu) after which, his left hip bone was fractured. In response to that, the patient can neither walk nor sit for long along time, which gave him so much pain. Looking back into the whole scenario the author felt very bad for the patient. She began to feel awful and dreadful through which, her patient was undergoing in those tough timings. His lack of ability to move by himself due to the pain caused by fracture and drain insertion was making his condition more terrified and prettified. Her emotions totally surpassed looking at the patient lying on the bed helpless and dependent on others for his care and for his debilitating condition. His powerlessness and painful condition simultaneously with his age factor were beseeching and begging to God as to end his life or to make him liberated from his disease process. The trauma took my attention and pushed me to uncover and highlight this issue.
Aforesaid scenario clearly explains the suffering of an elderly client at the end stage of his life. His diagnosis and his comorbids had made his health even worse; in order to help the patient, it was necessary to work on all of the signs and symptoms as to relieve the patient’s suffering. Goals play a major role from the aspect of care with their assessments that should be considered accordingly with the type of goal.
( Kaldjian, l. C., Curtis, A. E., Shinkunas, l. A. and Cannon, K. T., 2009 ). explained in their study that, "An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for the family/caregiver." ( Kaldjian et al., 2009). These goals can be utilized for incorporating a decision at the final stage of a life together with the patient’s preferred choice of treatment with their ethics and their clinical conditions. Hence, based on assessments and after reviewing the patient’s clinical presentation, a list of interventions was made and implemented on their fullest as to ease the patient’s suffering.
During the physical assessment, the patient appeared pale, drowsy, restless and irritable with Glass Coma Scale (GCS) 15/15. He had severe pain on the fractured leg of 3/5. His skin was very dry and had bruises on bilateral arms because of recurrent cannulation and blood sampling. Pitting edema of +2 was present on bilateral limbs and 2 degree bed sore was present on the sacrum, since the patient was CBR from the last two months. Together with this, he also has a very low urine output, i.e. 10ml/hour as the creatinine levels were highly raised. In addition, his appetite was greatly reduced as per the decreased physical exertion and metabolic demands. This reduction in appetite had impacted the patient’s weight on result of which, he had lost a significant weight in the last 2 months. His son verbalized during the interview that "My father is not eating anything since last 2 months, he hardly takes 2 to 3 spoons of food. This is why he had lost much weight in the last two months". The patient was also getting some medications for pain and to manage his physical symptoms which kept him drowsy all day long. Moreover, the PCN drain and the Foley's catheter was making himself perceived "Naapak". This feeling that he is not in the state to perform his religious practices understanding that he hasn't performed wadu. This was making him unable to offer prayer due to which his spirituality was highly impacted.
Aforementioned scenario depicts a clear picture of the patient suffering from physical and spiritual distress. In the physical domain symptom, relief was the main priority. The physical symptoms have an effect on all other domains that includes social, spiritual, emotional, physiological and sexual. Therefore, management of the symptoms in order to correct the patient’s well-being was primarily needed. Some factors that were prioritized are discussed below:
In the physical domain, pain relief was the one which is chiefly required. Pain is the main prevailing symptom in a terminally ill patient. Unremitting pain can be a great cause to increase suffering for the patients and their loved ones that can aggravate other symptoms ( Rome, Luminais, Bourgeois, & Blais, 2011 ). So, in order to minimize pain, the patient was encouraged for a deep breathing exercise, and the family members were asked to immobile the fractured leg. The patient and the family members were also told about the prescribed medications that should be taken on time.
Besides this, loss of nutrition was also one of the biggest hurdles in the improvement of the patient's condition. Eating a proper diet is very important, it helps in getting well from illness, lessen the side effects of the medications, helps in tissue repair, improving the electrolyte imbalance and makes the patients body stronger to fight against different diseases ( Holmes, 2011). Therefore, a teaching session was planned about the importance of good nutrition, but remained incomplete as the patient shifted next day. Small frequent meals were advised. The patient was asked about the food preferences as to encourage the patient to eat.
For maintaining the skin integrity, two hourly positioning and application of lotion for the dry skin was done so as to prevent excessive skin dryness and healing of the bedsore. The family was also advised for a regular dressing for the bedsore.
Then a passiveRange of Motion (ROM) with assistance was performed and encouraged so as to reduce the swelling of the bilateral limbs.
Spirituality was another affected domain that was analyzed from the scenario. "Spirituality is a fundamental element of human experience. It encompasses the individual's search for meaning and purpose in life and the experience of the transcendent" ( Puchalski, Ferrell, Otis-Green, & Handzo, 2014 ). The spirituality gives meaning to life. It could be the important factor that helps a person in coping with the disease process ( Puchalski et al., 2014). If this got disturbed because of any reason, it would had a great impact on the person's life. Similarly, if illness is the reason behind that, then definitely it would impact on the person’s healing process. Likewise, in this case, the patient was facing spiritual distress because of his illness. His fractured hip bone, drains and Foleys catheter were the main reasons which were causing distress and made him feel "Naapak". So family members were advised to recite Quranic versus and Tilawat in front of the patient so that, he can feel good. Else, the family was asked that, if the patient still feel "Naapak" because he hadn't performed wadu so the family can help in performing wadu for the patient. In this way, the patient will be able to perform religious practices and we can help the patient to satisfy his spirituality.
The whole journey of palliation was no doubt very interesting but really very challenging for a nursing profession. The goal is to satisfy the patient’s need in order to provide the patient a quality of life so that, they have a peaceful death. Yet, the essence of dealing an elderly palliative client with multiple chronic problems was also very difficult. Regardless of all the efforts, some of the aspects of care were still missing due to the shifting of the patient to the private wing on the day two of my rotations, patient was drowsy in response to the side effects of pain killers and so was not able to understand his disease process and some parts of the teaching provided and unavailability of the family members.
In a nutshell, as a palliative care nurse, there is a need to strengthen the skills so as to provide more effective care. The government should pay attention that, palliative care services should be available in every hospital, and the hospitals should be funded, drugs should be available with the availability of skilled professionals in every institution so that every person can have benefit from it from the time of the diagnosis till the end stage ( Stjernswärd, Foley, & Ferris, 2007 ). Moreover, hospitals should run community based programs so that, people who cannot reach hospitals can have care at their homes.
