Introduction
People seek medical assistance to help them treat various health conditions, but some individuals have illnesses that are not curable. Palliative care is an approach that utilises holistic assessments and relevant treatment strategies to achieve the best attainable quality of life for patients with life-limiting diseases and their families (Brown, 2016). The significance of such a practice is reflected in the notion that the process concentrates on helping the most neglected group of patients: those who are dying (Baines, 2011). For instance, the development of palliative care, which was initiated by Cicely Saunders, has changed the perception and management of cancer pain that was previously considered inevitable and not fully controllable (Clark, 2007). This paper explores the importance and specific aspects of the approach based on a case study of a palliative care client. Palliative care is meant to assist people during their last days and is associated with multiple internal and external influences.
Case Study
The palliative care situation centers around a male care home resident, who will be referred to as DC in this report. DC was admitted to the institution from the hospital at the age of 79 with a diagnosis of progressive prostate cancer with bone metastasis. The patient exhibited worsening shortness of breath with a non-productive cough, denied chest pain, and felt generally unwell. The results of renal function tests were quite stable, but DC had low iron parameters and anemia. The laboratory investigations for DC’s end-of-life review were as follows:
- Hemoglobin: 96
- Ferritin: 17.6
- Iron saturation: 13
- Sodium: 137
- Creatinine: 162
- Albumin: 31
- ALP: 206
The comorbidities identified in DC included T2DM, CKD, and HTN. Consequently, treatment focused on palliative chemotherapy and optimised analgesia with the list of medications containing oxycodone, ferrous fumarate, paracetamol, umeclidinium, docusate sodium, amitriptyline, and glargine insulin. In addition, DC’s GP (General Practitioner) prescribed him a gram of intravenous iron. DC’s treatment addressed his physical condition and was based on palliative care.
DC had the support of healthcare professionals, but his family was not involved during his stay in the care home. Seventeen years prior to the admission, DC’s wife left him and took away their daughter and two sons, leaving no information of their whereabouts. The patient hoped to reconcile with his family before passing away and, after a long search, received news regarding their location. DC wished to send gifts to his relatives and invite them to visit him but was told that they did not want to have any contact with him. Therefore, DC’s next of kin was his neighbour, who also had power of attorney. The client was seen by a social worker, GP, nurses, and people who used to live near him. Notably, DC was very reserved and primarily stayed in his room, not wanting to meet other residents at the care home’s lounge. However, after being rejected by his family, DC’s condition deteriorated, and he became depressed and jaundiced. Eventually, the patient denied and refused to take his medications or go to the hospital. Accordingly, not having loving relatives nearby has significantly worsened DC’s health.
Internal and External Influences
Effective client care depends on a variety of internal and external factors. Palliative care closely correlates with the concept of total pain, which broadens the understanding of end-of-life care (Baines, 2011). In particular, the construct explains the experiences of dying patients who are affected not only by physical pathology but also by a combination of other influences, including psychological and social impacts (Cherny et al., 2021). Consequently, such forces can be perceived as external or internal based on their relation to client care. For instance, the former kind of factors for DC from the case study primarily concern his estranged family, while the latter type is associated with his time in the care home. Accordingly, the experiences of persons with life-limiting conditions depend on internal and external influences represented by a variety of physical, psychological, and social forces.
Physical Factors
Clients’ experiences in palliative care are interconnected with physical factors. Such aspects are internal to each individual and can induce distress or burden (Cherny et al., 2021). Physical influences can be characterized by pain and non-pain symptoms, impairments, and treatments for primary illness and comorbidities (Cherny et al., 2021). Some diseases are more challenging to palliate than others, thus leading to differences in positive outcomes for end-of-life care (Cherny et al., 2021). The prevalence of physical symptoms varies across conditions and influences the necessary treatment. Most life-limiting illnesses cause pain and fatigue, but only some provoke confusion or delirium (Cherny et al., 2021). Consequently, each symptom requires distinct measures that have to be taken to assist patients. For instance, fatigue is quite common among clients in palliative care and prevents them from participating in basic everyday activities (Cherny et al., 2021). The sensation may also result in disturbed sleep patterns and reduced attention span (Cherny et al., 2021). Fatigue management requires pharmacological interventions and balancing between rest and activity periods (Cherny et al., 2021). Therefore, physical factors can influence care by provoking diverse symptoms that demand specific treatment.
Furthermore, physical forces that can be identified in DC’s case are related to his diagnosis of progressive metastatic prostate cancer. For instance, shortness of breath is among the symptoms exhibited by DC and is experienced by up to 77% of persons with advanced cancer (Cherny et al., 2021). Moreover, DC had bone metastasis, which is common among people with prostate cancer (Pituskin and Fairchild, 2021). The growth of bone metastasis can lead to substantial pain and can limit physical activity and mobility, which are frequently followed by weakness, poor appetite, and sleep disturbances (Pituskin and Fairchild, 2021). Therefore, cancer treatment requires pain management that involves external beam radiation therapy, analgesia, and supportive interventions (Pituskin and Fairchild, 2021). For example, DC’s medicine included analgesia and palliative chemotherapy. In addition, cancer pain is relieved through medications, among which opioids are the mainstay (Cherny et al., 2021). Oxycodone, for instance, was prescribed to DC and is one of the opioids utilized to relieve the ache (Cherny et al., 2021). Consequently, physical factors that directly affect care for DC can be characterised by pain, shortness of breath, and cancer-related treatment.
Physical influences can be evaluated as extremely consequential due to the effects on the experiences of all concerned within the palliative care situation. Patients diagnosed with cancer represent a chronically high-need population who require continuous family and emotional support (Pituskin and Fairchild, 2021). Moreover, palliative care encompasses a range of services delivered by physicians, nurses, pharmacists, support workers, and other specialists who aid clients and their loved ones (World Health Organisation [WHO], 2020). Finally, physical factors are likely to affect patients’ psychological well-being, provoking such demeanors as mood swings or impatience (Cherny et al., 2021). Therefore, physical forces are highly influential due to threatening lives, demanding ongoing involvement of many individuals, and impacting mental health.
Psychological Factors
The quality of end-of-life care is affiliated with a variety of psychological factors. Such influences are internal in relation to each person and comprise psychological disturbances, like grief reactions and demoralisation, and psychiatric disorders, including anxiety and depression (Cherny et al., 2021). Different life-limiting conditions are associated with symptoms that reflect mental health issues. For instance, low mood and nervousness are common in many clients with deadly diagnoses, whereas experiencing worry is moderately less prevalent (Cherny et al., 2021). Consequently, every situation demands the utilization of appropriate therapies to assist patients. For example, palliative care clients have to accept negative changes in their bodies, which results in up to 80% of such persons facing an existential threat, also known as death anxiety (Cherny et al., 2021). Existential threat worsens emotional well-being and generates a desire for a hastened death and suicidal thoughts (Cherny et al., 2021). Some therapeutic approaches to death anxiety are social interaction, which helps one feel valued through companionship, and music treatment, which improves positive emotions (Cherny et al., 2021). Accordingly, psychological forces derive from physical influences, hinder mental health, and require healing assistance.
Furthermore, psychological factors that can be identified in DC indicate him encountering an existential threat. In addition to causing patients to think of hastened demise, death anxiety often results in depression (Cherny et al., 2021). Accordingly, depression was recognised in DC, and it appears that the client did not have much desire to live due to the denial of medications and treatment. Notably, depressive mood is especially prevalent among persons with advanced cancer compared to individuals with other conditions (Cherny et al., 2021). Moreover, the progression of cancer confronts patients with a loss of the sense of continuity and meaningful activity (Vehling et al., 2019). DC expressed such symptoms when wishing to remain in his room and refusing to interact with other residents of the care home. A healing approach that could help DC is the Managing Cancer and Living Meaningfully intervention that incorporates techniques from cognitive existential, supportive-expressive, and meaning-centered therapies (Cherny et al., 2021). The method is a one-on-one psychotherapeutic practice oriented toward individuals with advanced cancer (Cherny et al., 2021). Psychological forces that directly impacted care for DC involve depression and a lack of will to live.
Psychological influences can be evaluated as highly important because they affect a person’s behaviour during their last days, which has considerable consequences for everyone involved. Palliative care concentrates not only on the experiences of clients but also on those of their loved ones (WHO, 2020). However, such factors as depression are associated with reduced quality of life, increased inpatient stays, and poorer survival (Cherny et al., 2021). Witnessing a person with a deadly condition being sorrowful is likely to heighten the grieving process for their families and carers. The patient’s relatives and friends may not cope and grieve in a restorative way, thus preventing them from communicating efficiently and making rational decisions (Cherny et al., 2021). On the other hand, healthcare professionals encounter loss when their clients pass away and may not adequately cope with grieving reactions (Cherny et al., 2021). As a result, medical providers may face troubles with personal and professional well-being due to repeated, intense involvement with distress (Cherny et al., 2021). Consequently, not addressing psychological forces can diminish patients’ quality of life and prevent their loved ones and caregivers from dealing with the loss.
Social Factors
The client’s experience concerning palliative care is closely connected to social factors. Such influences can be perceived as external due to being related to aspects outside of a healthcare setting. Similar to the above-discussed forces, social impacts are associated with distress and burden, like impaired role functioning, financial troubles, and abandonment by social support networks (Cherny et al., 2021). In particular, the latter element is especially important because interpersonal connections are crucial in psychological well-being and informal caregivers are indispensable partners of professional specialists (Cherny et al., 2021). Moreover, while other factors have some changes in their prevalence, social aspects of illness appear to remain across different phases of the disease trajectory (Lee and Ramaswamy, 2020). For instance, marital intimacy and children’s involvement seem to be equally important for patients in the initial, middle, and final stages of cancer (Lee and Ramaswamy, 2020). Spouses can exhibit support even with a mere physical presence, whereas clients’ offspring can give individuals with life-limiting conditions the courage to confront the disease (Lee and Ramaswamy, 2020). Therefore, social forces represented by the participation of patients’ loved ones can significantly affect end-of-life care.
Social factors related to DC’s case are mainly associated with his estranged family. DC’s wife and children were not in contact with him for many years and refused any interactions even when receiving news about DC’s condition. Despite having the assistance of professionals and his neighbours, the rejection from his relatives has negatively impacted DC’s health. The worsening of DC’s well-being can be explained by the notion that people with cancer consider spousal support critical in dealing with the illness and perceive children as sources of life (Lee and Ramaswamy, 2020). Individuals diagnosed with cancer are likely to develop attachment demands for security, intimacy, and support, yet DC’s needs were not met by his family (Vehling et al., 2019). Nonetheless, DC’s neighbor, who was his next of kin, played a meaningful role because connectedness with friends is found to be quite substantial in clients with advanced cancer (Lee and Ramaswamy, 2020). Accordingly, external social aspects such as DC’s family being away from him have hindered his condition and resulted in a lack of necessary support despite the help from professionals and companions.
Social forces can be evaluated as especially consequential because a person’s relationships with others can influence the health of everyone entangled in palliative care. First, DC’s case demonstrates that a lack of participation and assistance from family members can worsen one’s condition due to spouses and children being crucial partakers in facing a life-limiting disease (Lee and Ramaswamy, 2020). Second, while pain can disrupt interpersonal connections, insufficient social support can contribute to an increase in suffering (Cherny et al., 2021; Gomes-Ferraz et al., 2022). As a result, patients’ experiences of severe pain lead to higher levels of burnout, strain, and psychological distress in caregivers (Cherny et al., 2021). In addition, Gomes-Ferraz et al. (2022) propose that social aspects may be more pertinent for clients than physiological factors because the feeling of belonging, which is considered a primary human need, grows closer to death. Therefore, social influences are particularly significant as they can improve or hinder the quality of life for both people with incurable illnesses and negatively impact providers of care.
Communication
Since adequate palliative care depends on many individuals who are affected by multiple internal and external factors, and communication plays an integral role in supporting patients. Alongside such elements as symptom management and emotional assistance, communication is among the prerequisites to good health and is employed in various strategies that can facilitate the quality of end-of-life care (Brown, 2016). Clients, families, and professionals have to be in contact with one another to prevent unnecessary misunderstandings and distress (Department of Health and Social Care [DHSC], 2013). For example, people use unique vocabulary to describe their needs, and physicians may not ask patients about pain on a routine basis (Gomes-Ferraz et al., 2022). Consequently, symptom management may not be appropriate when medical specialists are unaware of certain details (Gomes-Ferraz et al., 2022). Accordingly, healthcare professionals must consider multiple aspects that may influence communication. For instance, excessive optimism may undermine one’s credibility, and disregarding cultural differences during interactions may cause substantial trouble (Cherny et al., 2021). Therefore, communication is a crucial element in palliative care that is required to unite families and specialists with the needs of clients.
Strategies
Palliative care practitioners can employ diverse strategies to facilitate the delivery of quality palliative care services. The selection of a specific procedure depends on each client and the factors that may affect them. For example, as mentioned above, a strategy that could be applied in DC’s case regarding psychological influences is the Managing Cancer and Living Meaningfully intervention developed for people with advanced cancer (Cherny et al., 2021). In comparison, a broader range of patients can benefit from such strategies as the RISK reduction assessment, oriented to enhance communication and produce details about clients’ cultural beliefs (Cherny et al., 2021). Improving end-of-life care requires a strategic approach based on a coalition of multiple professionals and individuals (DHSC, 2013). Medical specialists are expected to concentrate on co-ordinating care with individual plans for every patient and shared information to make appropriate clinical decisions (Leadership Alliance for the Care of Dying people, 2014). In particular, co-ordinating care is meant to reduce care fragmentation and ease transitions (Cherny et al., 2021). Consequently, palliative care practitioners can utilise strategies to address the needs of individuals with incurable diseases, and each approach should involve many professionals.
Practitioner’s Role
The quality of end-of-life care is interconnected with the role of the palliative care provider. Such specialists manage symptoms to reduce distress and burden, like controlling pain with analgesia in DC’s situation (Cherny et al., 2021). The practitioners support clients and carers by enhancing communication and promoting care coordination among medical professionals (Cherny et al., 2021). In their work, palliative care practitioners use their expertise but also rely on the assistance of other medical connoisseurs. For instance, specialists in palliative care can seek guidance from physicians to co-design treatment plans or ask for the help of ethics consultants when facing moral dilemmas (Cherny et al., 2021). Notably, palliative care clinicians often encounter ethical issues concerning incurable illnesses. The professionals may experience conflicts between their duties and what they deem right or confront the disharmony between beneficence, autonomy, justice, and non-maleficence (Cherny et al., 2021; Muldrew, McLaughlin, and Brazil, 2018). For example, DC’s case represents a quarrel between autonomy and beneficence, with the patient not wanting treatment that is considered good (Cherny et al., 2021). Therefore, end-of-life care depends on the competence of palliative care practitioners who endeavor to benefit clients.
Conclusion
To summarise, palliative care is an approach aimed at aiding people with incurable diseases while addressing multiple factors. The quality of end-of-life care is affected by internal and external influences, where physical and psychological forces refer to the former groups, and social aspects are primarily related to the latter. The case study about DC demonstrates the listed impacts in detail, with a focus on people with adverse cancer. For instance, physical factors are associated with various symptoms, including shortness of breath and pain. In comparison, social influences in DC’s situations are represented by him being rejected by his estranged family and not receiving enough interpersonal support. Consequently, all forces are interconnected because they can either mitigate or improve the client’s health and can affect the well-being of carers. A significant role is played by palliative care professionals who can use strategies to help patients and enhance communication between families and other specialists. Therefore, palliative care can assist individuals with life-limiting conditions but require efforts from many people to address the needs of clients based on diverse factors.
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