25 - End of Life Care Flashcards
What are the stats of death in Australia?
~150,000 deaths
~50% of whom will have a warning of their death
~30% of whom are referred to specialist palliative care services
The majority of Australians are not dying the way they would like to
What are the main end of life issues?
- Uncertainty – what will happen to me?
- Fear of pain and suffering
- Fear of the process of dying
- Decision-making: advanced directives
- Carer feelings of inadequacy
- Practical issues
- Anticipatory grief
What is palliative care?
Palliative care is an 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 assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
What are the benefits of early referral to palliative care?
Temel: advanced lung cancer patients
- Better quality of life and survived long (11.6 months vs. 8.9 months) compared to patients receiving standard care.
Bakista: newly diagnosed with advanced cancer
- Higher quality of life scores and mood compared to patients receiving only oncology care.
Cheng:
- Minimises caregiver distress and aggressive measures at the end of life
How should a clinician introduce specialist palliative care services?
- Referral to PC services should be considered at any time once treatment goal changes from curative to palliative.
- Refer to the PC health professionals as part of multidisciplinary team
- Raise the topic by being honest/open and use term palliative care explicitly
- Clarify and correct misconceptions about palliative care services
- Discuss role of the PC team
- Explain that the patient will still be followed up by primary health care team and/or specialist where applicable
What is the difference between bereavement, grief and mourning?
Bereavement: the state of having experienced a loss
Grief: the passive and involuntary reaction to that state of bereavement, including affective, cognitive, physical, behavioural, social and spiritual aspects
Mourning: the active processes of coping with bereavement and grief; social/public displays of ‘grief’, based on cultural, religious, philosophical beliefs
What is grief?
- Normal process of adjustment to loss
- Refers to the responses to the loss – emotional, physical, cognitive, behavioural, social, spiritual
- Grief is chaotic and unpredictable, you don’t recover. Mourning never complete (triggers)
What is complicated grief?
~10% of bereaved persons
- Defined as a deviation from the “normal” (in cultural and societal terms) grief experience in either time course, intensity, or both.
Many categories;
- Chronic: Unusually intense, overwhelming and/or prolonged symptoms
- Inhibited: Lacking the usual symptoms and/or onset of symptoms is delayed
Differential diagnosis; depression, PTSD
Who are at high-risk for complicated grief?
- Men who lose spouse
- Mothers who lose children
- Survivors of sudden and/or violent traumatic loss
- History of mental illness, addiction, abuse or trauma
- Low self esteem
- High dependency on the deceased
- High distress early in bereavement
What are some compounding factors that may affect grief reactions/response?
- Length of time to prepare for death
- Relationship between bereaved and the deceased
- Nature of relationship (Interdependence, Amicable – more “acceptance”/less other issues, Ambivalence – unresolved issues, conflict – regret)
- Resultant changes in lifestyle
- Physical and mental health of the bereaved
- History of loss
- Religion
Describe the results from studies on the “Widower effect”
9-year study, followed over half a million elderly couples (over age 65)
When one person becomes seriously ill or dies, that risk that the caregiver spouse will also become ill or die significantly increases
During the first 30 days following the death of a spouse
- A wife’s risk of death increases by 61%
- A husband’s risk of death increases by 53%
After one year
- A wife’s risk of death increases by 17%
- A husband’s risk of death increases by 21%
Reasons of “healthy” partner’s declining health: Increase in unhealthy behaviour; withdrawal from social networks
The level of risk for the caregiver’s death varies, depending on the type of medical condition of the ill spouse (highest risk: dementia, psychiatric illness)
Describe the early stage theories of grieving
Kubler Ross (1969): 5 stage theory of grieving
- Very influential in the field
- Originally for anticipatory grief, told they had terminal illness
Defined by the following distinct stages of grief
- Denial
- Anger
- Bargaining (let me live to see x)
- Despair/Depression
- Acceptance
Describe the early task theories of grieving
Specific tasks or processes to be “completed” in the process of grieving in order to deal with the loss
Worden (1982)
- Defined in an action-orientated way
Tasks of Grief
- To accept the reality of the loss
- Experience the pain of the loss
- Adjust to the new environment without the lost person
- Reinvest in the new reality
What are the benefits of stage/task theories of grief?
- Stage theories useful as therapeutic tools to normalise the experience of individuals
- Task theories define specific actions that the bereaved can take to help them cope with the loss
- Their simplicity makes them easy to understand
- Can explain experiences/feeling during anticipatory grief
What are the weaknesses of stage/task theories of grief?
- A definite number of responses to bereavement, suggesting a time-bound process
- Predictive, tend to over-simplify and generalise
- Normative
- Do not acknowledge the uniqueness of individual experiences of grief – outcome orientated (“moving on”)
- Cannot explain gender differences
- Common experiences may be pathologised