Intro to Palliative Part II

Question 1

What is the supportive care model?

Answer 1

Based on observing the nursing practice in Pain and Symptom Control clinic.
Model consists of six interwoven dimensions.
Dimensions are directed towards emotional aspects of dying and practical concerns of patients and carers.

Question 2

What is “valuing”?

Answer 2

Provides the context for supportive care.
Involves respect for a particular individual.
Primarily an attitude which underlies action.

Question 3

What is “connecting”? (as a dimension of the supportive care model).

Answer 3

Connecting with the patient and family.

• establishing a trusting relationship.
• sustaining the connection requires the nurse to spend time with the patient and family and to give of oneself.
• after the patient dies, connection continues for a time in the form of bereavement support.

Eventually the connection will be broken.

Question 4

What are some functions or roles of nurses in palliative care?

Answer 4

Promoting comfort, symptom management, emotional support, advocating for the patient and family, listening, promoting autonomy, family support.

Question 5

What is “empowering”? (as a dimension of the supportive care model)

Answer 5

Building on the strengths of the patient and family

Assess for and support effective coping techniques

Assist with decision making; supporting the choices they make; providing information

Letting them vent

Question 6

What is “doing for”? (as a dimension of the supportive care model)

Answer 6

Goal is to free up the person and family so that energy can be focused on really important areas for them

Includes pain and symptom management, co-ordination of care, and advocating for patient and family

Collaborate with patient/family to establish goals and care plan

Question 7

What is “finding meaning”? (as a dimension of the supportive care model)

Answer 7

Involves focusing on living and making the best use of time remaining
People need to be able to make sense of what is happening to them
Important to support realistic hope
Care for spiritual needs

Question 8

What is “preserving integrity (wholeness)” (as a dimension of the supportive care model)?

Answer 8

The core of the Supportive Care Model

Refers to the integrity of both the patient and the nurse

Nurse needs to be able to maintain a sense of self-worth and to take care of self

Integrity of patient and family is maintained through the balanced attention to all dimensions

Really means: holistic approach to providing care to the person and family

Question 9

What are some examples of self care?

Answer 9

Learning to receive as well as give
Learning to grieve
Replenishing oneself
Staying healthy
Being able to let go of personal agendas

Question 10

What is iPANEL?

Answer 10

Initiative for a Palliative Approach in Nursing: Evidence and Leadership.

Question 11

What is the background of iPANEL?

Answer 11

Background:
It is estimated that up to 70% of Canadians do not have access to palliative care (for any number of reasons, Carstairs, 2010).
While specialist palliative care units are essential, they are not appropriate for everyone with a life-limiting condition.
By offering a palliative approach in settings such as long term care, acute medical units and home, better care can be given to patients and their families experiencing the multiple transitions of chronic and life-limiting illness.

Question 12

What is the goal of iPANEL?

Answer 12

The goal of the iPANEL study is to further advance the integration of a palliative approach to nursing practice in every care setting.
The study is informed by nursing practice and as the cycle of research continues, in turn informs nursing practice.
Partnerships are essential – Health Authority, academic institutions, individuals.

Question 13

What is the core focus of the “valuing” dimension of the supportive care model?

Answer 13

Respecting the individual.

Question 14

What are some things that are part of the “valuing” dimension of the supportive care model?

Answer 14

This is about respecting the individual. This is about attitudes. This is global as well as individual. It is about respecting individuals’ worth, and recognizing that everyone is worth something. It might mean accepting patients as they are. So, looking at someone’s characteristics. We can’t possibly get along with everybody. You will connect with some patients better than others. However, we must always respect and value people.

Question 15

What is the core focus of the “connecting” dimension of the supportive care model?

Answer 15

This is about trust, and establishing a trusting relationship.

Question 16

What are some examples of things that can be done to establish trust? (Part of the “connecting” dimension)

Answer 16

Examples: giving information, listening with open body language, doing what you’ll say you’ll do (eg. “I’ll be back in 5 minutes” and actually come back in 5 minutes).
It’s about spending time with the patient and the family.
Giving a little bit of ourselves can help make this connection better. Sometimes we have to persevere with that a little bit. Not everyone is going to be able/want to/willing to connect.
Giving a little bit of yourself might mean crying, laughing, while still maintaining professionality. This might be more natural once you have made a connection.
Be available, do what you say you’ll do, maintain confidentiality.

Question 17

What is the core focus of the “empowering” dimension of the supportive care model?

Answer 17

Building on the strengths of the patients.

Question 18

How can the nurse help to empower a patient?

Answer 18

This is about building on the strengths of the patient. This means we have to take the time to find out what their strengths are. We need to give the patient and their family the control, and let them make decisions. We can do this by supporting them, giving them information, and establishing that trusting relationship.
Patients in the hospital feel absolutely out of control. It is not their own environment, they are unsure. They tend to defer to the “expertise” of the health care professionals.
It is important to also establish what their limitations are as well. Eg. If the family is there all the time, find out how much they want to help with care. Don’t assume they’re willing to do all the care (washing, dressing, etc) as some might want to do that, and some might not want to (maybe afraid of hurting the patient, not ready, etc).
Support decision making.
Sometimes we have to let them vent because this is a new and difficult situation.

Question 19

What is the core focus of the “doing for” dimension of the supportive care model?

Answer 19

This is the practical, physical care. It’s about managing symptoms.

Question 20

What is the focus of the “finding” meaning dimension of the supportive care model?

Answer 20

This is about focusing on living.

Question 21

What are some ways the nurse can help the patient to “find meaning” during the “finding meaning” dimension of the supportive care model?

Answer 21

. Making the best use of that time, helping patients and family understand what’s happening. It’s about being realistic, and supporting realistic hope (this can be quite challenging).
This might also involve caring for spiritual needs.
At this point, acknowledging death is important as well. Patients and families know they are at this point, and it is important to not ignore it.

Question 22

What is the core focus of the “preserving integrity” dimension of the supportive care model? (What does it involve on the part of the nurse)?

Answer 22

The core is wholeness. This is about the integrity of the patient and the family. It’s about balancing all the dimensions. It’s about recognizing and being comfortable with your own identity, and acknowledging your own feelings. Maintaining perspective is very important.

Question 23

What is the definition of “grief”?

Answer 23

Grief is a normal response that is unique to the individual, and is without a timetable or structure. It is commonly defined as the process of experiencing a variety of physical, psychological, social, and behavioural reactions from some type of loss.

Question 24

What are the two categories of loss?

Answer 24

Psychosocial loss

Physical loss

Question 25

What are some examples of psychosocial loss?

Answer 25

Divorce, death of a loved one, loss of meaning

Question 26

What are some examples of physical loss?

Answer 26

Wallet, body part, automobile

Question 27

What is “abnormal/complicated grief”?

Answer 27

Abnormal/complicated grief can be viewed as the failure to return to an individual’s pre-loss level of emotional well-being and functioning. This may be due to many reasons including unresolved issues, avoidance of loss, etc. No one definition exists and this may be due to the vast differences in individual and cultural responses and the variety of ways in which people demonstrate adjustment to loss (Cutcliffe, 2002). (We may be able to identify those at risk of experiencing complicated grief).

Question 28

What is “anticipatory grief”?

Answer 28

This is sometimes referred to as preparatory grief. Anticipatory grief refers to a grief reaction that occurs in anticipation of an impending loss. Anticipatory grief is the subject of considerable concern and controversy. Anticipatory grief is most often used when discussing the families of dying persons, although dying individuals themselves can experience anticipatory grief (National Cancer Institute, 2008). The term anticipatory grief is confusing as people are not preparing to grieve at some time in the future, they are grieving in the present, relative to a process of loss currently being experienced and projected into the future.

Question 29

What is “disenfranchised grief”?

Answer 29

Disenfranchised grief was coined by Doka in 1989 and is defined as “grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned or socially supported”. (Doka as cited in Kalich and Brabant, 2006).

Question 30

What are the five stages of the Journey of Grief?

Answer 30

Loss
Protest
Despair
Reorganization
Reinvestement

Question 31

What is “shadow grief”?

Answer 31

Shadow grief can be explained as a renewed sense of loss experienced around the anniversary of the loss, special occasions (like birthdays, etc). “Triggers” may cause the same feelings of grief as at the time of bereavement, perhaps a piece of music, a specific location, etc.

Question 32

What are four needs of people who are grieving?

Answer 32

Uniqueness of grief responses
Expectations one can have of oneself in grief
Needs of people who are grieving
Signs that may indicate unhealthy grief

Question 33

What are some signs that may indicate unhealthy grief?

Answer 33

Substance abuse
Withdrawing himself
Blaming other people/blaming themselves
Avoiding talking about the person/event

Question 34

What is “companioning”?

Answer 34

Companioning means “to walk with”, only. Most people with uncomplicated grief will recover with help of understanding friends/family but do not carry the person’s burden i.e. facilitate not “fix”, professional help may be needed.

Question 35

What is the definition of “mourning”?

Answer 35

Mourning is the critical expression of grief to the outside world. It is grief publicly exposed, that has been externalized from within the heart to without. These public expressions may include wakes, funerals, traditional clothing, cultural practices, etc. Mourning needs to run its course as an expression of grief in order that healing may occur.

Question 36

What are 8 things that affect the way someone grieves?

Answer 36

1. The nature of the relationship with the person who died.
2. The age of the deceased.
3. The nature of the death.
4. The unique characteristics of the deceased and survivors.
5. The ability of the person to make use of social support systems.
6. The person’s religious and cultural history.
7. Other crises or stress in the person’s life,
8. Previous experiences with death.

Question 37

What are some expectations that someone can have for themself when grieving?

Answer 37

• Your grief will take longer than most people think it should.
• Your grief will take more energy than you can imagine.
• Your grief will involve continual changes.
• Your grief will show itself in all spheres of your life; psychological, social, physical, spiritual.
• Your grief will depend upon how you perceive the loss.
• You will grieve for many things (both symbolic and tangible), not just the death itself.
• You will feel guilt in some form.
• You may have a lack of self-concern and self-esteem.
• You may experience spasms of acute upsurges of grief that occur without warning.
• You will have trouble thinking and making decisions: poor memory, organization and concentration.
• You will feel like you are going crazy.
• You may be obsessed with the death or preoccupied with thoughts of the dead person.
• You will grieve for what you have lost already as well as for the future.
• Your grief will entail mourning for the hopes, dreams, and unfulfilled expectations you held for and with that person.
• Your grief will involve a wide variety of feelings and reactions: some expected, some not.
• Your loss will resurrect old issues, feelings and unresolved conflicts from the past.
• You will have some identity confusion: due to the intensity and unfamiliarity of the grieving experience and uncertainty about your new role in the world.
• You may have a combination of anger and depression: irritability, frustration, annoyance, intolerance.
• You will search for meaning in/for your life and question your beliefs.
• You will find yourself socially acting in different ways.
• Society will have unrealistic expectations about your mourning and may respond inappropriately.
• You will have a number of physical reactions.
• Certain dates, events, seasons and stimuli will bring upsurges in your grief.
• Certain experiences later in life may resurrect intense grief feelings for you.