Best Practices for Managing Patients in Palliative Care

Freeman spoke about ways to achieve compassionate communication, such as through active listening, honest and open responses, genuine caring, using a compassionate tone, clarifying information, letting patients and families take the lead, addressing the “elephant in the room,” having a therapeutic presence, avoiding a sense of abandonment, and redefining hope.

She then discussed best practices for symptom management. “Rarely is pain ever just physical,” she said, noting that nurses should consider the psychosocial, spiritual, and cultural implications. With constipation, she said, it is the “only opioid side effect that the body does not build a tolerance to over time.” For nausea and vomiting, she said to consider the receptor site, including:

• Cortex: sensory input
• Vestibular system: motion
• Chemoreceptor trigger: drugs and products of metabolism, bacterial toxins, hyponatremia, and hypercalcemia
• Peripheral pathways: mechanical stretch from gastrointestinal distention/obstruction, infection, radiation, gastroesophageal reflux disease, local toxins, and chemotherapy.

Anxiety and depression impairs a patient’s quality of life and is “treatable even in hospice patients,” Freeman said. Risk factors for anxiety and depression include cancer, metabolic disorders, Alzheimer disease, Parkinson disease, poor pain or symptom control, certain medications, personal or family history, poor social support, and financial strain.

The greatest symptoms management needs at end of life include pain, dyspnea, delirium, nausea and vomiting, depression, and anxiety, Freeman said. She discussed the CARES tool (comfort, airway, restlessness and delirium, emotional and spiritual support, and self-care), which is an organized educational guide that addresses the most common symptom management needs at end of life.

Ninety percent of patients die in pain, and the focus of care should be comfort. “Provide as much time for the patient and family to be together as possible,” Freeman said, suggesting the following:

• Stop or modify vital signs
• Stop nonessential medications
• Clarify IV fluids
• Stop or reduce feeding tube
• Turn off monitors and alarms
• Stop or decrease labs
• Discontinue isolation.

The sensation of breathlessness can be reduced with the use of a fan, and nurses should explain agonal breathing versus suffering. Nurses should also control death rattle and emphasize the use of touch and talking to the patient. “Morphine is still the gold standard of care,” she noted.

For restlessness and delirium, it is important to educate the family that the patient lacks awareness of behavior and may be “peacefully confused.”

“Your humanity is needed the most,” said Freeman. “Always be available.” She noted that the family will become your focus during this time and to make sure families are getting proper rest and nutritional intake and to be available to answer their questions.

“We cannot change the fact [that] a patient will become terminally ill or die, but we have everything to say about the journey,” said Freeman. Be proactive, request palliative care consultations, and celebrate the person instead of focusing on their disease.

Freeman concluded with some self-care tips for nurses

• Be realistic
• Acknowledge a power greater than yourself
• Find comfort in knowing you did your best
• Celebrate the journey
• Separate personal issues from the patient
• Know that personal growth occurs best when the heart is broken

This session was supported in part by an educational grant from Tesaro.