Components of palliative care

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.

Wherever palliative care is used, its core ingredient is the quality of presence that the caregiver brings to the patient, a way of caring that enables discernment of the ongoing needs of the patient and family as they evolve and emphasises being alongside them. The focus is on all that is still possible in this time of multiple losses, the patient's and family's quest for meaning, and sustaining their experience of connectedness as they adapt to the challenges of the moment.

The term "palliative care" implies a personalised form of health care. It extends the healthcare professional's mandate beyond the biomedical model to the wider horizon necessary if one is to attend to suffering as well as the biology of disease, caring as well as curing, quality of life as well as quantity of life. The patient and family or significant others are taken together as the unit of care in assessment of needs related to illness. The aim of palliative care is to support optimal quality of life and to foster healing—that is, a shift in response towards an experience of integrity and wholeness on the continuum of the quality of life.

Beyond the physical

Meticulous attention to the alleviation of symptoms is the foundation of care of the whole person. Important psychosocial and spiritual concerns may be eclipsed by the presence of uncontrolled pain, nausea, constipation, and the other symptoms of advanced disease. Optimal treatment demands careful assessment of the multiple contributory factors to each symptom. If increasing doses of opioid are prescribed in response to pain that is escalating due to unrecognised existential anguish, the result will be persistent pain, opioid toxicity, and ongoing distress for the patient, family, and caregivers. If we are body, mind, and spirit, those domains are inseparable and interdependent. Thoughtful assessment of each complaint should be considered in the context of the patient's total suffering; therefore thoughtful assessment is mandatory.

Not just symptom control

Control of symptoms in palliative care commonly involves the concurrent use of six to eight or more medications. The goal is consistently to prevent rather than treat symptoms. Effective management depends on frequent adjustment to consistently sustain the minimal effective doses of medication and an emphasis on skilled nursing care as well as the use of the complementary skills of an interdisciplinary team experienced in end of life care.

Laboratory investigations—and even such non-invasive routines as monitoring blood pressure, pulse, and temperature—are undertaken only if doing so may lead to interventions that will enhance the quality of life.

Palliative care is founded on a philosophy that promotes sensitivity to cultural, religious, sexual, and other defining perspectives from the patient's point of view; the intent to meet patients where they are rather than where the caregivers feel they should be; sensitivity to the determinants of coping, particularly concerning major existential challenges for the

Palliative care is the approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual (World Health Organization, 2005)

Healing

Experience \ of suffering and \ anguish

Quality of life

Experience of wholeness and integrity

Wounding

The quality of life continuum

The quality of life continuum

Palliative care: selected philosophical perspectives and assumptions

• Nothing matters more than the bowels (Cecily Saunders)

• Humanise, personalise, de-institutionalise

• Clinical care grounded in qualitative and quantitative inquiry

• Experience of illness viewed as a narrative: relational, meaningful, filled with potential

• Assist progressive understanding of reality at a rate acceptable to the patient

• "Reality" as illusion; subjectivity of experience; acknowledgment of mystery

• Quiet efficiency, not hustle and bustle

• Focus on quality of living in the present moment, not death

• Accompaniment: empathic presence to the other in the moment

• Team: led by the patient; egalitarian rather than hierarchical

• Environment: centred on the patient, welcoming, peaceful

• Uniqueness, limitations, defences of the patient/family

• Healing of psyche: an innate potential

• Potential for adaptation, integration, reconciliation, transcendence

• Importance of compassion, celebration, community, paradox, humour

• With unresolved symptoms, "Review! Review! Review!" (Robert Twycross)

patient, family, and caregivers (death; isolation; freedom—the absence of external structure; meaning); attention to the meaning of the illness for the patient, family, and caregivers; and attention to the need for relating to people in an empathic way.

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