Palliative care is moving through an important period of expansion and development and it upholds a unique position in health care. More people need palliative care than any other health or social care services. This essay will be able to compare and contrast the current practice i.e. hospice and hospital with evidence based research. This essay will explore the history of past present and future of palliative care including the current policy and how palliative care will be in 10 years time. This will also go through the relevance of symptom management and pain control in palliative care.
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According to the NHS cancer plan (Department Of Health 2000) every year, over 200,000 people diagnosed with cancer and around 120,000 people die from cancer. Terminal care is an important part of palliative care(National Council for Hospice and Specialist Palliative Care Services (NCHSPC 1995). Palliative care grew from hospice which includes terminal care. The point at which terminal care begins is a subjective decision in the absence of an ability to accurately predict prognosis. How do we distinguish between progression and terminal? The word terminal is negative and passive. Palliative care upholds the principles of life and continuity instead of hailing sadness(Clarck and Seymour1999).
The goal of palliative care is achievement of the best quality of life of the patient and their families(WHO 2005).World Health Organisation (2005) defines palliative as “the active total care of patients whose disease is not responsive to curative treatment. Control of pain ,of other symptoms and of psychological social and spiritual problems is paramount” .The palliative care approach aims to promote both physical and psychosocial wellbeing (Addington and Julia,stated in Fallon M 1996) Palliative care is recognised by individualised, holistic models of care, delivered carefully, sensitively, ethically, and therapeutically by using skilled communication with attention to detail ,meticulous assessment ,and advancing knowledge(Balfour et al 2006).One of the core elements of good palliative care is effective communication, among health professionals and between health professionals and patients (Buckman,1993 wellbeing(Raudonis,1993;Hinton,1998).The essential components of palliative care are effective control of symptom and effective communication with patients and families and others involved in their care(O`Neil and Fallon 1996). The principles of Palliative care states as “Palliative care affirms life and regards dying as normal practice, neither hastens nor postpones death, provides relief from pain and other distressing symptoms. Offers support system to help families of patient’s illness and their own bereavement (Balfour et al,sited in Fallon M et al 2006)
The Development and contemporary practice in palliative care
Palliative care has become a public health priority across European countries due to increase in life expectancy and incidence of chronic illness (World Health Organisation(WHO)Europe 2004a; 2004b). Modern palliative care originated in development of St Christopher`s Hospice in London in 1967,recognising the unmet needs of dying patients in hospital (Chiarella 2006). Dame Cecily Saunders established the hospice and, with others, conceived of a comprehensive approach to dealing with the variety of symptom and suffering often experienced by patients with progressive debilitating disease. Careful observation of the use and effect of morphine and similar drugs are also originated in the hospice.(O`Neil and Fallon 1996). In the beginning palliative care was reserved only for those with incurable cancer .Palliative care now provided for other patients such as t AIDS , Neurological diseases including motor neuron disease and multiple sclerosis and some conditions of heart failure rather than concentrating only on cancer patients. ( O`Neill and Fallon 1996). In the past hospices provided only inpatient care and they were isolated from mainstream care. However in the last decades palliative care has gone through rapid changes and growth. In 1985 there were less than 100 hospices in the UK and now there are over 200 with 400 home care teams compared with less than 50 in 1985.(O`Neil and Fallon 1996). Today an impressive and bewildering array of palliative care education is available from short courses to conferences through to diploma first and higher degrees (Richard ,sited in Fallon M, 1996). Whatever the illness or its stage , informed by a knowledge and practice of palliative care principles and supported by specialist palliative care which should be practiced by all health care professionals in primary care , hospital and other settings by focussing on quality of life which includes good symptom control (NCHPCS,1999)District nurses play a vital role in community palliative care settings .Palliative and terminal care is an area of care that encompasses all the skills and knowledge passed by district nurses (Goodman et al ,19998). An example of importance district nurse awareness of service is the Marie Curie community nursing services ,developed to offer bedside nursing care for patients at home (Barnes, 1999).The opportunity to take education and training is important for community nurses when working with patients and families(Wikes et al 1998).The provision of 24hour service is a key component of community palliative care delivery. To improve the quality of care two complimentary models are used in UK. “The Gold standard Frame work -which is a primary care based approach to formalising best practice ,so that good care become standard for all patients every time(Thomas Sited in Fallon M,et al, 2002).The Liverpool care pathway provides multidisciplinary documentation and prompted guidelines towards achieving important goals for patients with cancer and their families in the dying phase (James 2002).Gold Standard Framework is for patients who nearing the end of life and Liverpool Care Pathway is for the last days or the last few hours of life . Presently patients have a choice for their situation.
Careful evaluation is the essential basis for symptom management and is the responsibility preferred place of death rather than spending their last days of life in an unfamiliar of both doctor and nurse. Evaluation is the vital steps in cancer pain (WHO 1998). The most widely accepted definition of pain is that given by the international association for the study of pain (IASP) ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage’ (Woodruff 1996). More practical definition is ‘pain is what the patient says ‘hurt” (woodruff 1996). In the palliative care setting where pain is usually chronic and progressive and of obvious significance to the patient some degree of suffering is common. Symptom should be treated promptly since they more difficult to treat, the longer they are left. Treatment must start as soon as the diagnosis is made. A symptom control is a major gaol with in palliative care and if the success of the goal is to be measured adequate methods of assessing symptom and the distress they cause are required.
The basic science of total pain mechanism is that anxiety fear and sleeplessness feed in to the limbic system and cortex. In turn the brain talks back to the spinal code modifying pain input at spinal levels. This then feeds back to the brain and a loop is established. With effective assessment and a systemic approach to the choice of analgesics using the WHO’s analgesic ladder over 80% of cancer can be controlled with the use of inexpensive drugs that can be self administered by mouth at regular intervals. (Falloon et.al.) According to the WHO pain ladder drugs should be administered in standard dozes at regular intervals in a stepwise fashion.
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Patients with cancer should be comforted with maximally achievable pain control and not leave in fear of inadequately treated pain. As survival of patients with cancer becomes longer, reliable pain relief is now a high priority issue that warrants both scientific research and industrial development of new devises and pharmacological agents that would make this pain relief complete safe and lasting.
When we turn in to the future and challenges in palliative care ,and where palliative care will be in 10years time, Palliative care will become more increasingly available to patients with non-malignant disease. Patients will be given more choice for their preferred place of care and where they wanted to be at the end of their life. More government funding, greater commitment, better education, and further research are some of the most important features of future palliative care. Greater political awareness and lobbying will also be needed. Introducing new models of care to bring good quality of care to a wider number of patients. Government offered a 12million investment over 3years to improve care for people coming to the end of their life lives. There will be an increasing number of hospices and will be developed world wide. More government funding are expected .palliative care will be more commonly available for patients with non-malignant disease. Palliative care will become more relevant part of education and public awareness to benefit palliative care for those who needed.
As medical science grows, we can expect the demand for palliative care will increase to a much higher level. And it will be vast growing part of social care around the globe .Palliative care must be considered as a service available routinely within main stream health care. In a world of limited or decreasing resources for health care , government in both developed and developing countries must allocate resources for cancer pain and palliative care in rational way. Increased research in to symptom management and assessment are highly prevalent and devastating clinical complication badly needed.
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