The challenge of providing palliative care in the nursing home part II: internal factors

Nursing homes are increasingly becoming the place of care and site of death for growing numbers of frail older people dying of chronic progressive illnesses. Despite this increase, empirical evidence suggests that providing palliative care in nursing homes is replete with challenges. In a previous publication, the authors examined challenges external to the nursing home that influence the provision of palliative care, and which may be beyond the nursing home's control (Wowchuk et al, 2006). This paper reviews the primary internal factors identified in the literature that affect the provision of palliative care and are, to some extent, under the nursing home's control. The internal factors include: i) lack of care provider knowledge about the principles and practices of palliative care; ii) care provider attitudes and beliefs about death and dying; iii) staffing levels and lack of available time for dying residents; iv) lack of physician support; v) lack of privacy for residents and families; vi) families' expectations regarding residents' care; vii) hospitalisation of dying residents. Suggestions for practice, education and research are provided.     

The challenge of providing palliative care in the nursing home: part 1 external factors

One impact of the baby boom generation and improved medical care is that nursing homes will be the place of care and site of death for growing numbers of frail, older persons dying of chronic progressive illnesses. The nursing home settings may appear to be an appropriate environment wherein residents could receive palliative care, but the literature suggests that provision of such care is replete with challenge. Some of these challenges are external to the nursing home environment and are beyond the setting's control, others have internal origins and to some extent may be under the home's control. In part I of this two-part article, we review and critically analyse the primary external factors identified in the literature -- characteristics of the residents -- as they impact on the ability of care homes to deliver palliative care.     

Dying in prison: providing palliative care in challenging environments

Prison health care in the UK is currently experiencing a period of change and, therefore, there are opportunities for the development of palliative care services. Some of the challenges of providing this element of care to dying prisoners are highlighted in this article.     

A framework for providing evidence-based palliative care

The development of a new inpatient hospice unit provided a valuable opportunity to consider ways in which nursing care is defined and documented. Three values which the authors felt should underpin nursing practice in the service were identified. This article outlines these values and describes the documentation framework that was adopted.     

Understanding palliative nursing care

Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life-altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non-pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.     

Aphasia: providing better nursing care.

The ability to communicate affects the total person and penetrates nearly every aspects of living. To best assist those persons experiencing language loss, the nurse needs to gain basic knowledge about the types of aphasia and about techniques to guide these persons in regaining communication skills that promote self-care. For the aphasic, relearning each small step in communication is a triumph. It is hoped that we can aid these individuals in experiencing many triumphs.     

Being a palliative care nurse in an academic hospital: a qualitative study about nurses' perceptions of palliative care nursing

The original philosophy of palliative care emphasizes the importance of the integration of compassion and medical science. The meaning palliative care nurses assign to their relationships with patients has been described in several studies. This qualitative research was undertaken in order to elicit the way nurses working on a palliative care ward in an academic hospital perceive their role and gain insight into the problems they encounter. The findings present two different perceptions held by nurses about the nature of their work. The first, the more prominent, is 'striving to adopt a well-organized and purposeful approach as a nurse on an academic ward'; the second is 'striving to enhance the well-being of the patient'. Nurses should be supported in the development of their palliative care approach and be assisted in reflecting on their practice in terms of a model of 'reflective practice' and in the development of 'moral imagination'.     

The nursing dimension in palliative care

In this 250-bed general hospital, nursing care for the dying focuses not on recovery but on self-actualization. In a broader context, patients also benefit from nursing's theory-based approach. A parallel between the evolution of the patient and the nursing process is established.     

Improving palliative care through effective communication

Effective communication in palliative care is instrumental in the development of the therapeutic relationship that should exist between patients and nurses, and the importance of it is well recognized by nurses working in this specialist practice area. This article examines the reason behind the need for effective communication, identifies systems of communication and explores the influence and value of contemporary communication theories and models in palliative care. It recommends that palliative care nurses develop a framework that will facilitate and give structure to the interview process with the aim of alleviating anxieties, encouraging situational control and promoting quality of life for patients.     

The challenge of providing holistic care in a viral epidemic: opportunities for palliative care

OBJECTIVE: To determine, using the perspective of a hospital-based palliative care service (PCS), the spiritual and psychosocial impact of a novel and potentially fatal viral epidemic on patients, their families and health care workers. DESIGN: Qualitative study using semi-structured interviews. The data were analysed using the constant comparative method and were validated using respondent validation. PARTICIPANTS: Eight palliative care workers. SETTING: Tan Tock Seng Hospital (TTSH), the hospital designated to manage all cases of Severe Acute Respiratory Syndrome (SARS) in Singapore. RESULTS: Disease containment resulted in isolation, where isolation meant the disruption of connectedness. This disruption of connectedness took place at multiple levels: in the patient himself, between the patient and the family, within the family, between the patient and the health care worker, between the patient and society, and between health care workers. As the nature of the disease was uncertain, prognostication was inaccurate. This created difficulties in helping patients and their families prepare for death. The fear of facing the unknown led to safety-seeking behaviours, which could be overcome by repeated exposure to the feared situation. The process of bereavement was disturbed, as traditional death rituals could not be performed by the family. Informants perceived themselves to be suffering as they suffered the same anxieties, fears and grief as the patient. CONCLUSIONS: Dealing with a novel viral epidemic creates spiritual and psychosocial issues similar to those encountered in a palliative care practice. Palliative care workers would do well to be aware of such issues and act proactively when such epidemics arise.     

Ethical arguments for providing palliative care to non-cancer patients

Palliative care professionals have begun to address the issues surrounding the provision of palliative care to non-cancer patients. Yet the situation remains inconsistent and morally unjustifiable. The duty to provide care, non-maleficence, beneficence, protecting the patient's best interests and respecting patient autonomy are key responsibilities which palliative care professionals have for all their patients, regardless of their diagnosis. On the grounds of justice as fairness, equality and equity, the current inconsistencies in the provision of palliative care to non-cancer patients are unfair unequal and inequitable. Professionals can no longer ignore their moral responsibility to address these issues and change their practice to include the provision of care for dying patients regardless of their diagnoses.     

The experiences of providing children's palliative care education in undergraduate nursing programmes--a discussion of some practical issues

Despite recent proliferation of palliative care services for children, and the fact that the needs of these children and their families are enshrined in current policy directives, the challenges of providing education for nurses within this area of practice is largely underexplored. This paper examines some of the key issues facing nurse educators who are involved in the delivery of palliative care content in undergraduate children's nursing programmes. Drawing on the extensive experiences of two nurse educators in children's palliative care education, research and practice, key issues which should be considered by those involved in curriculum development and delivery will be outlined. Such issues include ambiguity in terminology and resultant lack of conceptual clarity, the limited evidence base to underpin practice and education, the complexities of teaching sensitive topics to large groups and limited teaching expertise to deliver the content. Suggestions for addressing such issues will be outlined.     

Criminal prosecutions of physicians providing palliative or end-of-life care

Although medical malpractice suits commonly occur in medical practice, few physicians experienced criminal prosecution related to adverse clinical outcomes before 1990. Criminal prosecutions of physicians increased in frequency early in that decade, however, including a handful of cases involving palliative or end-of-life care. Reviews published around the end of the 1990s examined those prosecutions, listing causative factors and offering recommendations to prevent further cases. In this paper, we provide an updated review of criminal prosecutions of physicians providing palliative or end-of-life care, presenting three cases that occurred after 1998. We summarize these newer cases' chronologies and outcomes, comparing them to cases described in past reviews. Our analysis suggests that important factors not described in earlier reviews, especially conflicting views of the standard of care in hospice and palliative medicine, contributed to the development of these prosecutions.