APPENDIX I

CERTIFICATE IN ESENTIALS OF PALLIATIVE CARE

CASE REFLECTION

REFLECTIONS ON THE CARE OF A PATIENT WITH PALLIATIVE

CARE NEEDS.

NAME : [Link] GNANARANI

REGISTER NUMBER :08940901

CENTRE :JEEVODHYA HOSPICE

DATE : 25.07.2009

I declare that this is wholly my work , except where acknowledged specifically as the
published or un published work of other.

Signature

1
 Never Talk Defeat Use Words Like
Hope, Belief , Faith And Victory

NORMAN VINCENT PEALE

INTRODUCTION

WHERE I WORK

I Work as an ASST. Professor in the Medical Surgical Nursing

Department of Apollo College of Nursing, Chennai. I am at present
handling Medical Surgical Nursing theory Classes as well as supervise
students as they give care to patients in Apollo Hospitals Group. The
major clinical area I go for supervision is the Apollo specialty Hospital
where we care for Neurology and oncology, patients.

LEARNING PRIORITIES
Based on my past experiences in caring for patients and health
promotion, my caring philosophy has been to fight the battle against
cancer. But currently my learning priorities;

 To identify the patients who do not have the potential for cure but
are in need of palliative care.

 To identify the physical problems of patients and resolve them

CASE SUMMARY

Ms Bhuvaneswari was a 41 year old woman diagnosed and has ovarian

cancer, she used to come regular to Chemotherapy sessions and had
come to know her the past 6 months. She was also alluded to be a “un
cooperative” by Nurses. Her condition deteriorated day by day. With
clinical features indicating that she was dying.

Clinical features including Physical findings

She was referred with history of 4 months amenorrhea and vague

abdominal pain. Hirsutism were present. In the past, she was operated

2
upon 7 yeas ago in the immediate postpartum period for an ovarian mass
noticed at the time of delivery with elevated serum She also received 6
cycles of PEB chemotherapy regimen. Serum AFB levels returned to
normal range after surgery.

After two years she was again admitted into the general surgical
department on a compliant of abdominal lump and on laparotomy she
was found to have a mesenteric cyst of 15 x 12 cm arising from the root
of mesentery at ileocecal junction. Uterus, left ovary and other viscera
were normal. histopathology was reported as adenocarcinoma of
mesenteric cyst. She received 6 cycles of cisplatin based chemotherapy
and was on follow up for 3 years In view of the intermediate grade of the
present tumor she was given combination chemotherapy with
doxorubicin and carboplatin for 4 cycles. Her serum AFP levels returned
to normal. She was disease free two years after the last treatment and 7
years after the initial onset of disease.
Ovarian cancer is the sixth most common cancer (age standardized
incidence rate: 6.6/1000,000) and the seventh leading cause of cancer
deaths(age standardized morality rate :4.0/1000,000) among women
worldwide. In most of the population-based cancer registries in India,
Ovarian cancer is the third behind cervix and breast cancer. The age-
adjusted incidence rates of ovarian cancer vary between 5.4 and 8.0 per
1000,000 population in different parts of the country.

PHYSICAL FINDING
But now she presented with distended abdomen, abdominal pain ,
decreased bowel movement and breathing difficulty(pleural effusion)
indicating advanced illness.

PHYSICAL PROBLEMS

PAIN:

She refused medication especially pain medication as she thought pain

medications would sedate her and she wanted to spend with her two
daughters aged seven and fourteen. She seemed to be suffering from
constant pain. She ensured that Nurses should be at her bedside
constantly by repeatedly making calls asking for help to move or get
some water to adjust the dress or discontinue lines [Link] manifested
with furrowing of the forehead and had fluctuating levels of
consciousness , the analgesic that was given was fentanyl patch.

NAUSEA AND VOMITING:

3
Oral fluids were reduced and anti emetics were given

CONSTIPATION AND FECAL IMPACTION Manifested as general

abdominal pain agitation. Laxatives and digital evacuation was one.

BREATHELESSNESS

She reported , ‘I cannot get enough air’. I explained that oxygen may not
help her but positioned her in fowlers position and provided cool fan
blowing over her.

DEATH RATTLE:

Suctioning was tried but failed , fluids alone were reduced .

INCONTINENCE OF BOWEL AND BLADDER was managed by adult

diapers

Mottling of skin and cool extremities indicating decreased peripheral

circulation occurred
PSYCHOSOCIAL ISSUES:

- After resolving her physical suffering to an extent, her emotional and

spiritual needs were taken into account.

Most of the work that was done by me was involved in helping her
though her perceived loss of role as a mother.

Children’s Problems: Will I be able to adjust living with the grand

mother-where which school etc. she talked in her phone and recording
was made, video were done.

Communication Issues:

1. Patient
The patient talked to me freely initially , but after a few weeks, she
seems to be with drawn. One day she asked me suddenly a question , I
think I am dying, I wondered whether she really had found out about her
condition or should I hide the truth from her., but I soon realized that

4
she needed to lean the truth, so that she could make her plans of
settlement. I quietly nodded my head in agreement, expecting her to
break down and cry. But she smiled with relief and told me’Thank God, I
don’t have to pretend to you people that I don’t know about my
condition.’

2. The Family

When she could not take any oral fluids not even by the NG tube, her
family approached me asking, why don’t you give atleast IV fluids? I tried
to explain that IV fluids will not be of much use to their mother. but they
were never convinced about their reply and they talked to the physician
and it was decided to give only one pint of fluid per day. Also the patient
wanted to be taken home , but the husband and family wanted the
Hospital to try all the measures possible in the hospital and felt ,we were
not fulfilling our responsibilities and trying to abandon the patient.
The family never used to allow as to give back care as they thought we
were disturbing her [Link] I realize that they were right about
it.

3. The Health Team

The health team generally supportive in nature but at point they wanted
to insert a central venous catheter, but the attending physician refused
to allow the insertion a central venous catheter or infuse total parenteral
nutrition.

4. Investigations reasons

AFP levels (25.6U/ml) She

underwent right adnexectomy. The
laparotomy right ovarian mass of For knowing about the malignancy
25 x 14 cm The histopathological of the right ovary revealed alpha-
examination sinus tumor of right fetoprotein secreting sertoli leydig
ovary. cell tumor of ovary

Abdominal examination revealed a

cystic mass of 10x 8 cm size in the
left fornix and normal sized uterus.
Serum AFB levels were elevated
(101.0 U/ml) laparotomy with total For evaluating recurrence of
abdominal hysterectomy and left Metastasis to the left ovary
salpingo ovariotomy &
omentectomy. l

5
CT of the abdomen For evaluating extent of Metastasis
to the omentum and peritoneum
leading to bowel obstruction.

OUT COMES OF THE PATIENTS

 Satisfaction with care delivery

 Symptom resolution and reduction
 Perception of being well cared for
 Compliance with the treatment plan
 Knowledge of Patience and families
 Trust and collaboration among care providers
 Improved quality of life were the Nursing Sensitive outcomes
during the palliative care of my patient

Involvement or contribution of other team members

The primary physician of the Madras oncology group, surgical

oncologist where all involved in the diagnosis surgery and treatment
plan of the patient. But during the terminal illness palliative
specialist, special duty nurses and social nurses help was enlisted
and they help in the relief of the symptoms of the patient especially
the pain of the patient.

Ethical Issues involved in this case

Veracity whether to tell the patient that she is dying was followed
after overcoming the initial fear

Autonomy of the patient was respected when she wanted to go home

and spend her last days at home. The principal of non maleficence
was considered when administering the opioids, though I had fears
that I am hastening the dying process related to side effected of opiods
which is respiratory , depression. The principle of beneficence was
considered do her only good and never accept to hasten the dying
process by euthanasia. The principle of justice and futility of
treatment was considered when refusing to accept for IV fluids or
total parental nutrition even when subjected to pressure by the family
or the health team. DNR was instituted for the patient while in the

6
 hospital according to the wishes of the patients husband , but was
not witnessed in the Hospital as she was sent home before she could
die.

Alternative strategies to improve the care of such patients

Training for nurses in the palliative care , more support from the medical
fraternity. Support by specialist by having a palliative specialist in the
team having adequate equipment such as infusion pumps , improved
staffing to attend to the needs of the patients, more number of hospices
institutionalizing for the care of patients

Conclusions

Personal insight:

By caring for the patient , I understood , how much nurses and other
health care professionals feared approaching the family with the bad
news and not able to give hope. How difficult it was when we thought we
should always have the solutions for the patients problem, but I now
realize that being there for the patient and conveying the sense of caring
is more important than resolving the problems of the patient because
patients themselves realize we are not GOD

(B) Professional knowledge and skills

1. Physical
I learnt the management of pain, and that opioids reduce the intensity of
breathlessness.
I also understood that constipation is the definite problems with the
opiods use especially with advanced CA ovaries due to the infiltrated
nature of the growth. I also learnt that IV fluids or oxygen are not the
right choice of treatment for patients during terminal stages.

2. Psychosocial`
I understood that patients undergo denial that they are not going to die,
anger at the health team especially nurses ,family members or god and

7
bargain for a few more weeks or months to settle their perceived
responsibilities and then depression that nothing much could be done
for them by any one and finally acceptance that they have to live with it
and that they alone can work towards dying peacefully. Hearing may be
the last sense next to touch that is lost while dying , so even when the
patient is non verbal there is scope for nursing care by reassurance ,
touch etc.

[Link]
Patients get troubled by guilt and state that Karma or the sin has let to
the decease and would like o change their ways , they try to resolve
conflict with those whom they have wronged and people who are more
spiritual but not religious or at peace at them selves and with others.
Dying stage usually is not as fearful or painful as perceived by the people
who watch the person who is dying , because the consciousness is
clouded

Policy and innovation in practice : Palliative Nursing should be

integrated into the oncology nursing curriculum of the nurses. Older
nurses who have not been exposed to palliative need to be educated
through refresher courses. Policy for obtaining and distribution Oral
Morphine by the Government should not be only through the single
window system but should be more liberalized as the prevalence of
cancer in India is very high and India is the largest producer of opium
Institutions which can care for the patients during the terminal illness
should be established , this will reduce the cost of caring for a patient in
a tertiary care centre as it is unnecessary for the patient to be care by th
super specialist after the decease has advanced. Wide dissemination of
knowledge regarding palliative care should be made to the general public,
so that the burden of caring for a patient becomes lighter and the
suffering of the patient is minimized.

Ovarian cancer has the worst prognosis among all gynecological

malignancies. The overall 5-year survival is approximately 45%, primarily
due to late stage at diagnosis of the disease. Appropriate
multidisciplinary care is quite meager. Most of the ovarian cancers are
initially operated by general gynecologists since trained gynecological
oncologists are very few in the country. Many of the patients receive
suboptimal management due to logistics and socioeconomic constraints.
A large number of patients belong to rural areas and have poor access to
specialized health care. The prohibitive cost of antineoplastic drugs to

8
continue with the treatment. Advanced stage of disease at diagnosis. In
appropriate management a, and poor compliance to therapy all together
are responsible for the dismal survival rates.

Every Hospital should have a palliative specialist and palliative nurse ho

ill be able to give consultation and care to not only all the cancer patients
but also those who are in end stages of renal and cardiac decease and
cardiac failure also.

Reference

1. Poli UR,Swarnalata G,Maturi R,Rao ST , “Recurrent alpha-

fetoprotein secreting sertoli leydig cell tumor of ovary with an
usual presentation.” Indian Journal of Cancer January-March
2009/Volume 46/Issue 1

2. Mainsh, Bisht etal (palliative care in advance cancer patients in

tertiary care hospital in uttrakanth , Indian Journal of Cancer
January-March 2009/Volume 46/Issue 1

3. Lichter, Hunt E “Last 48 hours of life”:.J palliative care 6 : 7 to1 5

4. Ingersoll GL , Mc intosh E etol :Nurse sensitive out comes of

advance practice J ADV Nurse 32: 1272 – 1281 ; 2000.

5. Barriers to care for dying-Nursing times, May 24 2001 Vol 97

No.21

6. Marie Mass’signs of approaching death’ AJN Feb 1999 Vol 99-No;2

7. Zerwehl ;How hospice nurses help patient confront [Link]

TRUE LETTER

8. Robin Fisher,”Tools of the heart “ AJN July 1996 Vol 96 No

7,pp56,57.