Nursing Non-Pharmacological Interventions for Palliative Care Patients

Life is made up of years that mean nothing and moments that mean it all (Redneck Girl). Miss Z was nursing student in XYZ hospital: she encountered a 62 years old male, who was diagnosed with soft tissue sarcoma on the left side of the chest two years ago. Currently he was bedridden and he was admitted two weeks ago with complains of diarrhea and generalized weakness for which he was being given symptomatic treatment. However, his condition deteriorated with time and was now suffering from pain, ineffective breathing, vomiting, edema and constipation. Due to the illness, the patient’s physical, psychological, social, spiritual and cultural domains were affected. However, this paper will highlight the physical and psychological domain in terminal illness, interventions, recommendation and also lead to the conclusion. These two domains are significant to discuss because they were highlighted in this case and usually patients with advanced cancer undergo physical and psychological deterioration. 

Methodology: Case Report.

Results: Physical domain is the most significant to deal with, in order to reduce other sufferings. Pain, dyspnea is the common and most distressing symptom in patients with terminal cancer. 

Recommendations: The care providers nurses and doctors must have some prior knowledge of such institutions that might help patients and families.

Life is made up of years that mean nothing and moments that mean it all (Redneck Girl). During my clinical, Miss Z was nursing student in XYZ hospital: she encountered a 62 years old male, who was diagnosed with soft tissue sarcoma on the left side of the chest two years ago. Currently he was bedridden and he was admitted two weeks ago with complains of diarrhea and generalized weakness for which he was being given symptomatic treatment. However, his condition deteriorated with time and was now suffering from pain, ineffective breathing, vomiting, edema and constipation. Due to his condition, he was unable to perform his hygiene care by himself and therefore needed assistance. Along with this, he was also tensed for his children’s future as his wife had passed away ten years ago and there was no one else to care for his two children. When Miss Z saw the patient, at first, she was helpless and felt like she was actually experiencing her patient’s problems as it brought pain, suffering and feeling of sorrow and regret. At that time multiple questions arose in her mind such as why this happened to him? Are we really reducing the sufferings and improving the quality of life? Is her patient satisfied? Who will take care of his children when he will die? Furthermore, Miss Z realized that although we possess caring attitudes, feelings and emotions towards patient regarding death, but the pain of separation and unmet needs can only be understood by the one who is going through the near-death experience. When, she came back on clinical next day then she did not get the chance to meet her patient as she got to know that he had finally passed away. Due to the illness, the patient’s physical, psychological, social, spiritual and cultural domains were affected. However, this paper will highlight the physical and psychological domain in terminal illness, interventions, recommendation and also lead to the conclusion. These two domains are significant to discuss because they were highlighted in this case and usually patients with advanced cancer undergo physical and psychological deterioration. Also, cancer pain influence physical, psychological, and spiritual aspects so it is important to manage pain and control the physical symptoms in order to promote quality of life and a good death (Lin, Lai, & Ward, 2003; McSherry, 2011).

Physical domain is the most significant to deal with, in order to reduce other sufferings. Pain, dyspnea is the common and most distressing symptom in patients with terminal cancer. Literature also supports this notion by saying that pain and breathlessness are a common cancer-related symptom in patients with advanced disease (Wells et al., 2003; Thomas, Bausewein, Higginson, & Booth, 2010). On assessment, severe pain on a scale of 7 was verbalized by the patient. According to literature, adequate pain assessment plays a significant role in the cancer pain experience (Zaza, & Baine, 2002). However, pain and dyspnea were interrelated in a way that as the sarcoma invaded the entire chest wall; therefore, the patient faced difficulty while breathing and has to breathe forcefully. Ultimately this led to pain but the patient was unaware of the reason behind it. Also, because of the pain, the patient was unable to communicate effectively and perform his ADL. For this, only pain medication was given by staff. Whereas, Miss Z worked on the non- pharmacological management which looked so little but worked for her patient as she explained the purpose of pain and how to assess pain to caregiver. Along with this, mind diversion through pictures, deep breathing exercises, pillows to support body, positioning had been done. On the second day, her patient became unconscious and was gasping to which the doctor concluded that the patient will die at any moment. According to literature, gasping has been observed in mammals at the beginning and at the end of life (Srinivasana et al., 2006). For this, oxygen was provided by staff and the head side of the bed were elevated to kept a fan near the face and did proper positioning. Apart from this, nausea, vomiting and constipation were the side effects of the pain medication; for which appropriate teaching was given to the family to reduce this complication. 

Apart from physical, psychological domain is also essential. From the Edmonton scale, it was found that due to the physical illness, the patient was psychologically disturbed and agitated and had no desire to live further with pain. According to literature, spirituality-based interventions are important in patients with lack of desire and hopelessness (Mystakidou et al., 2009). Therefore, Mizz Z tried to divert her patient’s attention by giving tasbih to him (religious counter). On verbalization, patient felt depressed and tensed related to his children’s future as he was the only support for his children and was concerned about the financial burdens. Also, her patient felt isolated for which he expressed his desire to meet his daughter, but as his son was not willing to break the bad news with his sister, Miss Z patient was unable to meet her. According to literature, patients with unmet needs show higher psychological distress which has an impact on the quality of life of the dying (Morasso et al., 2000). Ultimately, this affects the recovery. For that Miss Z faculty and she counseled the patient’s son to break the bad news to his sister so that his father could meet his daughter. They explained further that if he shared the news with his sister then she would not blame him about keeping her in the dark regarding her father’s death. In this way, they convinced the patient’s son who then told his sister; thus, they helped in fulfilling the wish of her patient. However, the patient’s condition also had an impact on the caregiver as his son was tensed and fearful about losing his father. According to literature, cancer patients with distressing symptom have a psychological impact on family and caregivers (Thomas et al., 2010). For that, they gave time for the son to cry and ventilate his feelings and they assured him that crying is a normal response. According to literature, when patients are closer to death, they want to get out of bed and talk to loved ones. Similarly, they encouraged the caregivers to talk to their father even if he would not respond and say whatever they wanted to as hearing is the last sense that disappears (Morrow, 2010). Also, they helped the patient’s son to take finger prints of his father with ink pad so that he could keep it with him always. In this way, the caregiver became stable after talking and keeping the finger prints with him. After having a talk with the son, she saw tears in her patient’s eyes even though he was unconscious and not responding. According to literature, “Tears are a natural part of saying good-bye. They do not need to be hidden or apologized for, as they are expressions of love.” (Mayo clinic staff, 2011, p. 1).

This case led us to think one step ahead in a way that silence doesn’t mean the absence of problem so, it is important to identify and work on hidden domains as well. Previously, they didn’t have the same feeling of death for patients as they have for their own family members. However, after working closely and being involved in patient and family care they felt as if they were working with their family member and similarly in future, they will help and support their patients with full determination. Although, the element of care is similar in palliative but improving the quality of life by reducing sufferings is the main goal therefore, interventions were done on various domains. On the other hand, there were some limitations that need to be taken into consideration. When Miss Z patient told her that after his death there would be no support for his children and that he was also not financially stable, at that time, she was speechless and didn’t do anything. She was not able to refer them to some institution that would help such individuals. For this, we will recommend that care providers must have some prior knowledge of such institutions that might help patients and families. Secondly, as her patient was in severe pain therefore, she could not ask multiple questions regarding death and dying. For this she will recommend that health provider must ask the beliefs of a patient regarding death on admission or when patient is communicating well. Thirdly, she requested the staff to attached cardiac monitor when patient was gasping but they refused even though the monitor was available, which should be taken into consideration. After her clinical hours, the patient died and at that time she wasn’t there to help his children in the bereaving process. So, it is the key responsibility of assigned nurse to help family in bereaving process. Along with this, a recent study showed that quality of life can be improved by psychological interventions particularly, cognitive behavioral therapy and supportive group therapy (Mystakidou et al., 2009). So, these therapies should be practiced to improve the quality of lives of terminally ill patients. 

In a nut shell, although various domains were affected due to the terminal illness but physical and psychological was the highlighted one. In death and dying situation, a nurse requires the skill of effective communication, determination and hard work. As a health provider, we tried to provide comfort, support and care to the patient at the end of life. Hence, Government, NGO’s and civil society must work together to face this challenge head on and to improve the quality of life of terminally ill patients.