The purpose of this assignment is to write a report on an episode of care received by a patient with palliative care needs, in which I have been involved in. It will also demonstrate my ability to meet the learning outcomes of the module, such as the critical evaluation of the policy landscape within which continuing, palliative or cancer services are delivered and the analysis of the integrated nature of service delivery, relevant in patients with palliative care needs and how it has enhanced the delivery of care. Integrated care is defined as “the act of making a whole out of parts; the co-ordination of different activities to ensure harmonious functioning” (Marriam Co, C & G.1998).
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In order to comply with the guidelines on confidentiality and consent as stated in the Nursing and Midwifery Code of professional Conduct (2008) and the guidelines of the University, I obtained permission from the ward sister, to use a patient’s information in my report. I also asked the patient directly for his permission, explaining the purpose of the report and in order to protect his anonymity, I would change his name, not mention the placement by name and not divulge any identifiable information about him. I have also explained he can withdraw consent at any time. Consent has been documented in the patient’s notes, from this point onwards I will refer to my chosen patient as “Phil” and the area as my placement.
The report will be structured in sections. Section 1, will introduce the focus and structure of the assignment. Section 2, will give a brief description of “Phil”, his problems, diagnosis, care needs and who will be involved in his care.
Section 3, will discuss three key government policies, relevant in the care of people in the palliative stage of their illness.
Palliative care is defined by the World Health Organisation (2002) as
An approach that improves the quality of life of patients and their families facing the problem 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. (www.helpthehospices.org)
My chosen policies are The Department of Health End of Life Care Strategy (2008) The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer and The Liverpool Care Pathway. I will be comparing and contrasting the patients experience to policy recommendations and how they have been implemented at a local level. Policies are described by Blank & burau (2007) as an action taken by the government, in order to improve, prevent or prioritise to achieve an end goal.
Section 4, will contain an overview of salient points regarding the policies implementation, highlighting where areas could be improved and make any recommendations for future practice.
Overview of my patient and the episode of care
“Phil” is a sixty five year old male, divorced, lives alone within the city and has one son. He was diagnosed with leukaemia twelve years ago in 1997. Alexander, Fawcette & Runcman (2006) describe Leukaemia as “a malignant disorder where abnormal and excessive of proliferation immature and ineffectiveness of blood cells”. There are two types, acute and chronic Leukaemia “Phil” has chronic Leukaemia, Alexander, Fawcette & Runcman (2006) further state, Leukaemia is rare within the UK and the incidence varies geographically, causation is not fully understood but exposure to radiation, chemicals, viruses and cytotoxin medication may increase incidence. People diagnosed with this type of Leukaemia can live for many years after receiving treatment.
Phil’s Leukaemia was indolent for several years, until 2002 when he received a course of chemotherapy (cyclophosphamide), in 2006 was given more chemotherapy (fludarabine). Then in 2008 he was treated more aggressively with a higher dose of combination chemotherapy (cyclophosphamide & fludarabine). Phil retired at this time and had continued to deteriorate until being admitted to the hospital in April 09 with a fever where he was treated with intravenous antibiotics, his health declined further until he was admitted onto my placement for symptom control, however Phil moved very rapidly into the terminal stage. Terminal stage is defined as the end phase of life, at this stage someone’s life will normally be in the last days, where someone can be in the palliative phase for months or years (Kay 2003).
After the admission and assessment care plans can be formulated whereby Phil’s individual care needs can be met, Phil’s problems are pain, constipation and a general unsettled feeling about how is son is coping with his illness. Involved in his care will be the specialised palliative care doctors, nurses, the spiritual care coordinator and a bereavement counsellor who will support, Phil’s only son, who at this time, has taken time out of University in order to be close to his father, at the end of his life.
Policies and how they have been applied in the episode of care.
3.1a Summery of The Department of Health End of Life Care Strategy (2008)
The Department of Health End of Life Care Strategy (2008) was developed to improve standards of care across the United Kingdom (UK) for all adults at the end stage of life. It aims to provide frameworks that will guide our health care system putting great emphasis on the needs and wishes of the patient and their families. The key aims are, engaging groups in local communities to become more aware of end of life care. It aims to ensure that patients approaching the end stage of life have their symptoms managed to maintain optimal quality of life. It calls for the careful assessment of needs for people that are approaching the end stage of life, and recommends the use of the single assessment process (SAP). It aims to ensure that services accessed are coordinated to provide seamless care. It aims to ensure that people approaching end of life are considered holistically, the holistic approach covers the physical, psychological, social and spiritual needs.
The policy’s main aim is for all health care providers to adopt and develop the use of the Liverpool care pathway or an equivalent. There is also great emphasis on involving and supporting carers and families, the policy calls for the need to provide information to the carers and family members about the person’s condition and also to support them on a practical and emotional level this is to include bereavement care. The Department of Health End of Life Care Strategy (2008)
3.1b How the policies have been applied in practice to my patient
Phil was admitted using an adaptation of the single assessment process, (SAP), section 3.36 of the policy supports the use of this process. The SAP took place with the doctor, nurse and me, the student nurse present. It is not expressed in the single assessment process Guidance for Local Implementation (2002) that the doctor and nurse do this assessment together, but my placement feel it’s a more effective system when both parties are present and can feed back to other members of the team, this also avoids the patient having to repeat their details again.
This sharing of information is carried out by the nurse, who admitted the patient, information is passed on during end of shift handover, where it is attended by nursing staff and health care assistants. The nursing staff also discusses his needs with other relevant people who will be involved in Phil’s care such as the spiritual care coordinator and bereavement councillor and family support team. Multidisciplinary working is covered in the policies key aims, this is carried out during weekly multidisciplinary meetings. Where all parties are in attendance that are to be involved in patient care, during meeting decisions are made regarding who needs to be involved and best ways of providing care.
Integrated care provides patient with the best standard of care, however in order for it to work to the best effect again communication and team working has to be a priority, this is supported by Barrett, Sellman & Thomas (2005) who state “the quality of care received is dependent upon how effectively different professionals work as a team”, all these professionals write in the same patient notes to share information. The Nursing and Midwifery Council (2008) state good record keeping is one of the most important aspects of communication and enhances patient care.
Further aims are to ensure pain and suffering is alleviated through skilful symptom control, this was carried out with the use of a combination of analgesic to alleviate his pain and also medication for constipation. Kay (2005) states that constipation is one of the most common side effects of analgesics and patients should be commenced on laxatives from the outset.
Again in accordance to the policy key recommendations, patient and family involvement and support is vital and has been implemented, by way of, Phil and his son have been informed about his condition and their concerns addressed at all times by staff. Phil’s son is also receiving counselling and will continue to be offered bereavement counselling after his father’s death as mentioned in the key recommendations. Luton (1995) states if patients and their families have an understanding that the symptoms can be controlled, dignity is maintained and feel supported by staff, are better prepared to cope with the difficult and emotional time ahead.
A further recommendation was to raise the profile of end of life care. Whilst on placement a group of six form students from a local school who are currently studying health and social care, asked to spend some time at my placement, to raise their awareness of end of life care which is part of their course learning.
In accordance to the policy, as well as Phil’s health needs the assessment also encompasses his social and spiritual needs. Phil has been attending the day centre facility adjacent to my placement, for around six months, this has been a time where he has been able to have some social interaction away from home and has continued to be offered to attend.
The spiritual coordinator has also spent time with Phil addressing any wishes he may have or talking about his feelings regarding his illness, he only expressed that his son received support which he has and he die at my placement. Although he declined, Phil was also given the chance to access support services that would facilitate him to leave lasting mementos for his son for example, a memory box or letters.
My placement also supports the use of the Liverpool Care Pathway as recommended in the policy and it was applied to Phil when it was apparent he had reached the end of life stage. The End of Life Care Strategy (2008) have been very well implemented and my placement and has considered the persons needs as well as supporting the family needs.
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3.2a Summery of The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer(2004)
The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer (2004) advises those who are responsible for the delivery of cancer care about how to ensure their patients, families and carers are well supported the policy has made twenty key recommendations. This includes for example, key personnel who are involved in the in the delivery of care required in people with palliative care needs, will oversee that the policies guidance is being implemented. Patients and their families are involved in decisions about their care and encouraged to make their voices heard.
The policy recommends that a holistic approach should be adopted in people affected by cancer have full support physically, emotionally, spiritually and socially. The guidance recommends that patients have access to support groups and have help and advice regarding money or access to help with personal needs. The guidance recommends that systems are available 24 hours a day and equipment is provided without delay to support patients to stay at home. (The National Institute for Clinical Excellence Supportive and palliative care services for adults with cancer (2004).
3.2b How the policies have been applied in practice
The guidance recommends that key personnel will oversee that the policies guidance is being implemented. In my placement this is overseen by the head of nursing staff, together with the introduction of clinical governance to my placement, clinical governance is a frame work that monitors care that is provided, ensures care is of the highest standard and is evidence based(www.dh.gov.uk). A holistic approach was adopted during his care as mentioned earlier and Phil and his son were involved in all decisions made regarding his care on arrival, yet when he became semi- conscious, although it was explained to him what care he would receive, he was no longer capable of responding and all decisions were then made by nursing staff and doctors.
Although some of the guidance may have applied to Phil if he had of went home as intended on admission. His health declined so rapidly I can no longer comment on whether some of the policies recommendations were well implemented or not, yet arrangements were in process for Phil to have a home visit with the occupational therapist who would assess his needs at home and any adaptations that would be needed.
Support from day hospice to help with personal care and he was to continue to visit the day centre. Day hospice is another of the large array of service providers needed when providing care for patients with palliative care needs. The team have very good relationships between outside service providers and seem to have communicated well during Phil’s illness.
3.3a Summery of the Liverpool Care Pathway
The Liverpool Care Pathway (LPC) was developed by the Royal Liverpool University Trust and the Marie Curie Centre in Liverpool in 1997. Its aim is to bring the model of care used in hospices to all health care setting. It is an integrated pathway that guilds the health care workers in providing “best practice”. Its key aims are to improve the knowledge of the process of dying and to improve the quality care, delivered to patients in the last day and hours of life.
The focus of the LCP is upon initial assessment, ongoing assessment and care after death. This incorporates the spiritual beliefs of the patient, what the patient and their family understand about the illness and what arrangements have been made after death. Someone is commenced onto the pathway when it is agreed by the multidisciplinary team that the person is dying and have two or more indicators that the team will recognise. These indications are, the patient has become bed bound, the patient is semi-conscious, the patient is only able to take sips of water and the patient is not able to swallow tablets.
The LCP also gives guidance on areas such as symptom control, prescribing medication that may be needed, stopping other treatments that are no longer required, providing comfort for example mouth care. This documentation is to be filled out every four hours. The policy focus is that the patient’s symptoms are controlled and four core drugs are administered (www.mariecurie.org.uk). Kay (2003) states, that all patients will receive Morphine for pain, Midazolam to control agitation, Cyclizine for nausea/vomiting and Hyoscine that controls secretions or an equivalent drug to the same affect at the end stage of life.
3.3b How the policy has been implemented to my patient in practice
Phil was admitted for symptom control of pain, on admission he was fully mobile, he was eating small amounts and coherent. However his health deteriorated rapidly, within days he needed support of two people when getting in and out of bed, over the next five days he was not eating, he could no longer talk and could not swallow his medication, as stated in the policy these are the indications that he has entered the terminal stage. It was agreed by one of the doctors and a staff nurse that he was now in the terminal stage and the LCP should be applied. One of the doctors and a staff nurse went together, yet the doctor took the lead when explaining to Phil and his son what changes were occurring. The staff nurse stayed after the doctor left to support both Phil and his son.
My placement has a leaflet explaining the symptoms of the end stages of life which was given to Phil’s son. Providing information is one of the policies main aims and as mentioned previously knowledge can better prepare patients and their families for the end stages of life. Phil was reassessed at this point and the LCP was now the only paperwork that was to be filled out. The LCP is a very structured plan that can be altered in some ways to give a more individual approach, yet I did not see it being changed in any way regarding Phil’s care or any other patients whilst on placement.
The LCP does provide an efficient checklist, however after the initial assessment I felt the care became just a ticking box exercise and as Phil was now semi- conscious the only time nursing staff went into his room was to provide comfort and on occasions the time had lapsed after the four hour recommended time stated in the policy, this view is supported by Kelly (2003) who states:
that care of the dying may be standardised to such a degree that reality is reduced to a flow diagram and palliative care is simply a series of boxes to be ticked be professional care givers.
However Taylor (2005) states that if the LCP implementation is carried out by health care professional that are fully trained in palliative care and the use of the LCP the documentation can be used to its full potential.
Phil was also prescribed the recommended medications and died peacefully with his son by his side. After death care is also a goal of the policy and shortly after he had died a member of staff explained to Phil’s son that nursing staff would wash and dress his father also asking if he had expressed any wishes and to contact his chosen funeral director, after which Phil’s son was given as much time as he wanted to spend with his father. Before leaving my placement Phil’s son was given the phone number of the bereavement counsellor. After Phil’s son has left the funeral director is contacted again by one of the nursing staff to collect the body.
This report has covered policies that are used in people with palliative care needs, the overriding message from all the policies is, support of patients their carers and families, the need to approach care from a holistic aspect, covering the person’s physical, psychological, social and spiritual needs. For patients to be involved in decision making and be informed about their treatments and the care they will receive. All the policies call for a high standard of care delivery for people with palliative care needs and end of life care. The policies aim to ensure that patients approaching the end stage of life have their symptoms managed to maintain optimal quality of life until death.
This placement has taken place in a palliative care unit and whilst writing this piece I am very aware that my placement area offers a very high standard of care that applies most of the principles of each policy. The Department of Health End of Life Care Strategy (2008) states that the principles of the policy should be offer to all dying patients. However, during my time spent on the ward there was only ever one patient admitted for end of life care that did not have cancer, to which staff commented on why she was here. So it seems that cancer patients are part of a privileged group when reaching the end of life.
For future practice I would recommend that the LCP has a section that requires nurses to check on patients more regular, not to provide any care but reassure patients and their families their needs are being met and staff are always on hand. I would like to see all patients with palliative care needs be offered the same quality of care as cancer patients receive at a hospice. Yet I am aware that providing this standard of care to all people would over stretch the already limited available resources. Yet my own philosophy of care is not driven by money but providing the best care for my patients regardless of illness.
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