This paper focuses on analysing patients’, caregiver’s and health workers experiences and identify future research questions on management of symptoms, proper nutrition, and hydration at end-of-life. The authors report on low funding in medical research especially in the palliative care which has highly contributed to little knowledge and substandard services to patients with conditions that require palliative care and their relatives. In this additional analysis conducted as an in-depth investigation, searched to gather respondents’ perspectives and experiences they have ever had during palliative care. This study aims to provide a report of the experiences people have ever had regarding symptoms, hydration, and nutrition management during palliative care. It involved 1403 participants from the United Kingdom. The oldest themes at end-of-life identified in the study were the pain, breathing difficulties, terminal agitation, nutrition, and hydration. The survey suggested that it was difficult to assess pain, agitation, nutrition, and hydration needs especially in patients with cognitive impairment. Hence, made the management of symptoms difficult and hence created more distress to patients and the relatives. Though the caregivers’ response indicated that the primary goal was to reduce pain in their dying patients, a large number of patients who participated in the study pointed out that there was less pain during management. In the research, the caregivers questioned the ability of the health professionals to manage patients in palliative care which they suggested led to the death of the patients.
The authors of this article are; JessicaBaillie, a lecturer in School of Healthcare Science at Cardiff University in the UK. Jordan Van, Godwin, a lecturer in the School of Social Science at Cardiff University. The authors have published several articles which have been peer reviewed and accepted. Hence, makes this article credible and their results reliable for use in other future researches. The authors found from their study there is a knowledge gap and necessity for advanced symptom management methods for individuals at the end-of-life. Therefore, there is necessity for more research into symptoms assessment and management for patients in palliative care. This research will be relevant in my assignment since it contains responses given by the participants which indicate their experiences and perceptions of symptom management in palliative care. Though the answers were more towards the participant interest, the results obtained were not biased. The study will enable me to explore, interpret and understand current research evidence regarding symptom management and its effectiveness. Therefore, giving information that can be used to improve the services offered during palliative care.
Was this Primary or Secondary research? Primary research
Study Objective or Aims The aim of the study was to determine how effective is the Care Program for The Last Days of Life (CAREful) is in improving care and comfort to palliative care patients.
Setting in which the study was conducted Patients in the same acute geriatric word were assigned same group.
Inclusion / Exclusion Criteria Acute geriatric patients at the last days of life
How was data collected? Data was collected using questionnaires
What data was collected? Clinical information, primary and secondary outcomes of the intervention
How was the data analysed? The data was analysed using Mixed Linear Regression Model
What ethical considerations are associated with the research? Participant consent was obtained for inclusion in the study
Findings/Results
Sample size – How many participants were included in the research? the research included ten hospitals. Through randomization five were selected for the intervention and the other five as control. 451 acute geriatric patients were included in the study
Was the sample size justified? The sample size was justified using CAED-EOLD total score
Key Findings/ Results The program reduced pain and other symptoms to patients under intervention
There was comfort around dying in patients who were under the intervention
Discussion Less satisfaction to the relatives about the CAREful program
Conclusion The authors concluded that CAREful should be utilized in giving care to patients at the terminal stage to provide comfort
Strength of the research The data was appropriately analysed making the results credible
The recommended sample size was used
Weakness of the research The patients were not informed about the study
How do the study findings inform the clinical practice The study findings inform the health professionals on the right procedure to manage pain and other symptoms during the last days of life.
Summary
This article focused on improving the quality of intervention offered to geriatric patients at the phase of end-of-life in hospitals. This study aimed to determining the applicability of the CAREful program in enhancing the quality of service and providing comfort to a patient at the end-of-life phase. The implementation strategy of this study involved training of staffs, a guide on the implementation of the program and assessment process to monitor the quality of the program application. The randomized controlled trial conducted in Belgium used the hospitals as a unit of randomization and the patients as units of analysis. Five hospitals were randomly selected to implement the CAREful intervention and five other hospitals to be the control group. There was masking of patients and their relatives on intervention allocation, and the staffs were unmasked. The controlled group received standard care while the intervention group went through a structured program. The study found that the Program for the Last days of Life was effective at providing comfort and enhancing quality of care at the end-of-life phase. This result led to a conclusion by comparing it to the Liverpool Care Pathway (LCP). Nurses reported comfort during the sickness and death time in the patient under intervention a result that was not true with the family members. For patients who were under the program, there was improved communication and reduced pain symptoms, the irrelevant medication stopped, and the number of those under oxygen treatment during their death had decreased as compared to those who were in the control group. However, the relatives felt neglection of their patient after withdrawal of some of the treatment during the program.
The authors of this article are; Kim Beernaert, a senior researcher in the Faculty of Medicine and Health Science at Ghent University. Joachim Cohen, a professor at Vrije Universiteit Brussel. Tinne Smets, a senior researcher at Vrije Universiteit Brussel and Rebecca Verhofstede a professor in Medical Sociology, Health Science. Massimo Constantin, a researcher in the Palliative Care Unit in Italy. Kim Eecloo, a lecturer at Ghent University. Nele Van Den Noorgate, a professor in Vrije Universiteit Brussel and Luc Deliens, a professor at Vrije Universitiet Brussel. The authors have published many peers reviewed article, and hence their study is credible. Thus, the results can be used for more research. This article is relevant in my assignment since the results obtained that indicates the Care Program for the Last Day (CAREful) being useful in symptom management and improvement of the intervention provided in palliative care for the elderly. This study will be appropriate in guiding the health professionals and the relatives on the practical means of handling the patients at the end-of-life phase to provide comfort and relieve pain.
As affirmed by Temel et al. (2017) symptom management is essential in palliative care to reduce distress in patients and the relatives as well. Lack of proper control at this last phase hasten death (Baillie et al., 2018). Research has shown that there are inadequate assessment and control of pain and symptoms even at terminal phase (Dy et al., 2015). Therefore, it is critical to developing methods of symptom assessment to promote quality of care and prolong life. Unfortunately,extensive research on palliative care has not been conducted due to lack of funds to facilitated them. Thus, has led to suboptimal services from the health provider due to lack of enough skills to deal with symptoms associated with the end-of-life phase. As shown by Baillie et al. in their research, some patients’ relatives doubted the professionalism of the staffs providing care. Due to reluctance to administer some treatment for fear of overdosing and fasten death. Though symptoms assessment in the unconscious patient may be impossible, as suggested by the researcher, further research should be done to improve the current method in use in symptom management in palliate care patients.
Symptoms mostly experienced during the end-of-life include pain, agitations, dyspnea, respiratory secretions, anxiety, nausea, and fatigue. As according to Kwon (2014), pain in cancer patients remain undermanaged even after the development of novel analgesic. He attributed this to challenges related to health professionals, patients, and healthcare systems. These multifaceted barriers, therefore, ought to be alleviated to help reduce pain in the terminally ill people. Several methods have been developed to manage the symptoms. Interventional pain management techniques have been widely used to cab pain in terminally ill patients. Drugs are administered to reducesymptoms such as pain and anxiety related to end-of-life. For instance, cancer patients where pain may be uncontrollable, opioids have been used to control pain and limit side effects (Ferrari, Giardini, Negri, Villani and Preti, 2017). For patients with multiple conditions such as diabetes, hypertension and life-threatening disease like cancer pain management requires equalization of all the elements involved carefully (Aisenberg and Petito, 2017). However, this intervention does not provide comfort to the patient before death.
Liverpool Care Pathway (LCP) is a method developed with the aim of improving life and providing comfort to a patient at the end-of-life phase (Costantini et al., 2014). It was designed to guide the health professionals and relatives on how to provide care to a terminally ill patient to ensure the patient is free of pain and distress. However, as research indicates, the LCP protocol of symptom management has not been universally accepted for use in palliative care (Flo and Engedal, 2017). As explained by Flo and Engedal, studies conducted to determine the relevance, validity, and reliability of LCP are limited, and hence the protocol is not acceptable in nursing homes and hospitals. In a review conducted by Meneses-Echavez, Flodgren and Berg indicated that there was an insignificant difference between the Liverpool care pathway and the standard palliative care given to patients at the last phase in life. Therefore, the authors recommend Standard palliative care system. In the research conducted by Beernaert et al. (2017), they noted that in only one study conducted in Italy using LCP indicated positive results in managing symptoms in palliative care.
Beernaert et al. developed the Care Program for the Last Days of Life (CAREful). They researched to determine the effectiveness of the program in providing quality services in palliative care and support to patients during their last days of life. The study clarified the effectiveness of the program in providing comfort and reducing distress in patients with terminal illnesses. As suggested by Teno et al. (2013), delayed treatment of terminal diseases make it difficult to manage end-of-life diseases and symptoms. The CAREful program that is provided by the health professionals to a patient, while providing relevant information to the relatives. Equips the nurses on how to provide care to patients under palliative care and prepare the family for the death of their loved one. Palliative care services showed improvement in the quality oflife of the patients. Caregivers and patient satisfaction and provide comfort to the patient end-of-life phase (El-Jawahri, Greer and Temel, 2011). However, in Beernaert et al. research noted that the relatives of the patient under the CAREful program were not satisfied with the service since the improvement led to discontinuation of some drugs and food which they thought was mistreatment to their patients. Hence more information needs to be given to the relatives for them to understand and appreciate the intervention (Mello et al., 2016).
Other symptom management methods applied in palliative care include physical exercise therapy and music therapy. As asserted by Navigante and Morgado (2016), physical exercise plays a significant role in relieving fatigue in cancer patient. The practices facilitated the improvement and hence prolonging of life and provided comfort for the patient during his last days. Music therapy for the past 30 years has been successful in reviving, maintaining,promoting emotional, physical and mental health for patients with terminal illnesses (Warth, Kebler, Hillecke and Bardenheuer, 2015). He clarifies that researches have been conducted and indicated success in palliative care in providing comfort at death
From the researchers conducted in this field of terminal care, it is evident that several methods can be put into practice to enhance the quality of life and provide comfort during the death phase. This information should be used to improve medical training for palliative care professionals to equip them with the necessary skills for their service to the patient. The data can also be used to develop medical guidelines on palliative care service (kalies et al., 2018).
Summarily, it is very critical to manage symptoms inpatients receiving palliative care. Methods and tools for symptom assessments should be developed to facilitate quality services providence to the patients.Further research should be conducted to provide more information on appropriate services to be delivered to the terminally ill people to meet their nutrition; hydration needs as well as managing the symptoms. Relatives play an essential role in this system. Therefore, their inclusion and guidance in helping the patient arecritical.
References
Aisenberg, G., & Petitto, G. S. (2017). Invasive Care Can Still Be Palliative Care in Patients With Advanced Cancer.
Baillie, J., Anagnostou, D., Sivell, S., Van Godwin, J., Byrne, A., & Nelson, A. (2018). Symptom management, nutrition and hydration at end-of-life: a qualitative exploration of patients’, carers’ and health professionals’ experiences and further research questions. BMC palliative care, 17(1), 60.
Beernaert, K., Smets, T., Cohen, J., Verhofstede, R., Costantini, M., Eecloo, K., Van Den Noortgate, N. & Deliens, L. (2017). Improving comfort around dying in elderly people: a cluster randomised controlled trial. Lancet, 390, 125-34
Costantini, M., Romoli, V., Di Leo, S., Beccaro, M., Bono, L., Pilastri, P., … & Franceschini, C. (2014). Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial. The Lancet, 383(9913), 226-237.
Dy, S. M., Kiley, K. B., Ast, K., Lupu, D., Norton, S. A., McMillan, S. C., … & Casarett, D. J. (2015). Measuring what matters: top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. Journal of pain and symptom management, 49(4), 773-781.
El-Jawahri, A., Greer, J. A., & Temel, J. S. (2011). Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. J Support Oncol, 9(3), 87-94.
Ferrari, P., Giardini, A., Negri, E. M., Villani, G., & Preti, P. (2017). Managing people with diabetes during the cancer palliation in the era of simultaneous care. Diabetes research and clinical practice.
Flo, E., & Engedal, K. (2017). The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review.
Kalies, H., Schöttmer, R., Simon, S. T., Voltz, R., Crispin, A., & Bausewein, C. (2018). Barriers for the implementation of guidelines in palliative care—results from a national survey of professionals. Supportive Care in Cancer, 26(6), 1943-1952.
Kwon, J. H. (2014). Overcoming barriers in cancer pain management. Journal of Clinical Oncology, 32(16), 1727-1733.
Mello, B. S., Massutti, T. M., Longaray, V. K., Trevisan, D. F., & de Fátima Lucena, A. (2016). Applicability of the Nursing Outcomes Classification (NOC) to the evaluation of cancer patients with acute or chronic pain in palliative care. Applied Nursing Research, 29, 12-18.
Meneses-Echávez, J. F., Flodgren, G., & Berg, R. C. (2016). Use of Liverpool Care Pathway at the End of Life.
Navigante, A., & Morgado, P. C. (2016). Does physical exercise improve quality of life of advanced cancer patients?. Current opinion in supportive and palliative care, 10(4), 306- 309.
Temel, J. S., Greer, J. A., El-Jawahri, A., Pirl, W. F., Park, E. R., Jackson, V. A., … & Rinaldi, S. P. (2017). Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 35(8), 834-841.
Teno, J. M., Gozalo, P. L., Bynum, J. P., Leland, N. E., Miller, S. C., Morden, N. E., … & Mor, V. (2013). Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. Jama, 309(5), 470-477.
Warth, M., Keßler, J., Hillecke, T. K., & Bardenheuer, H. J. (2015). Music therapy in palliative care: A randomized controlled trial to evaluate effects on relaxation. Deutsches Ärzteblatt International, 112(46), 788.
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