Chapter 7 - Palliative care

When the cancer that later took his life was first diagnosed, Senator Richard L. Neuberger remarked upon his 'new appreciation of things I once took for granted—eating lunch with a friend, scratching my cat Muffet's ears and listening to his purrs, the company of my wife, reading a book or magazine in the quiet of my bed lamp at night, raiding the refrigerator for a glass of orange juice or a slice of toast. For the first time, I think I actually am savouring life'.

Better Homes and Gardens magazine

Palliative care is an approach to the management of a person with a terminal illness. It implies that at some point in the management process there is a change from the objective of curing the disease to that of controlling and alleviating symptoms. 1

To enable a person to live in dignity, peace and comfort throughout their illnesses means responding to physical, psychological, emotional, social and spiritual needs. 1

Palliative care is comprehensive, continuing, multidisciplinary patient care that involves the patients and their carers, consultants, domiciliary nurses, social workers, clergy and other health professionals who are able to contribute to optimal team care. The fundamental principles of palliative care are: 2

• good communication

• management planning

• symptom control

• emotional, social and spiritual support

• medical counselling and education

• patient involvement in decision making

• support for carers

The diseases

Palliative care applies not only to incurable malignant disease and HIV/AIDS but also to several other diseases such as end-stage organ failure (heart failure, renal failure, respiratory failure and hepatic failure) and degenerative neuromuscular diseases.

The special role of the family doctor

The general practitioner is the ideal person to manage palliative care for a variety of reasons— availability, knowledge of the patient and family, and the relevant psychosocial influences. A key feature is the ability to provide the patient with independence and dignity by managing palliative care at home. Someone has to take the responsibility for leadership of the team and the most appropriate professional is a trusted family doctor.

Most patients and their families require answers to six questions: 3

• What can medical science offer?

Caring honesty is the best policy when discussing the answers to these questions with the patient and family. Never lie to a patient and avoid thoughtless candour.

Support for patients and carers

Studies have indicated that the most common complaints of patients are boredom and fear of the unknown. This highlights the importance for the attending doctor of the following points:

• Give emotional support.

• Listen and be receptive to unexpressed 'messages'.

• Treat the sufferer normally, openly, enthusiastically and confidently.

• Show empathy and compassion.

• Employ good communication skills.

• Give honest answers without labouring the point or giving false hope.

• Provide opportunities for questions and clarification.

• Show an understanding of the patient's needs and culture.

• Adopt a whole person approach: attend to physical, psychosocial and spiritual needs.

• Anticipate and be prepared for likely problems.

Special points worth emphasising are:

• The patient needs a feeling of security.

• Provide reassurance that the patient will not suffer unnecessarily.

• Be prepared to take the initiative and call in others who could help, e.g. clergy, cancer support group, massage therapists.

• Patients must not be made to feel isolated or be victims of the so-called 'conspiracy of silence' in which families collude with doctors to withhold information from the patient.

• The worst feeling a dying patient can sense is one of rejection and discomfort on the part of the doctor.

• Always be prepared to refer to an oncologist or appropriate therapist for another opinion about further management. The family and patient appreciate the feeling that every possible avenue is being explored.

Note: Always establish what the patient knows and wants to know.

Symptom control

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