Introduction

Palliative care: p provides relief from pain and other distressing symptoms; p
affirms life and regards dying as a normal process; p intends neither to hasten nor
to postpone death; p integrates the psychological and spiritual aspects of patient
care; p offers a support system to help patients live as actively as possible until
death; p offers a support system to help the family cope during the patient’s illness
and in their own bereavement; p uses a team approach to address the needs of
patients and their families, including bereavement counselling, if indicated; p will
enhance quality of life, and may also positively influence the course of illness; p is
applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy; p includes the
investigations needed to better understand and manage distressing clinical
complications
 Terminal cancer

• Terminal cancer refers to an advanced stage when curative treatment is Terminal

cancer refers to an advanced stage when curative treatment is no longer useful,
the disease is assessed to be incurable and the patient’s condition is progressively
deteriorating
 Communication
• Communication is exchanging ideas or feelings between two or more
people on a common background or agenda. Communication can be
verbal or non-verbal. The communication process is complex, and
more than 70% of communication occurs through non–verbal means.
Good communication is a trainable skill. Proper communication is vital
for the well-being of the patient and the family and satisfaction from
work. Studies show a significant unmet communication need for
information about the disease, prognosis, treatment options, intent,
side effects, and complications.
 Effective communication
• Build rapport: Take the time to establish a relationship with the patient and their family members
Listen actively, show empathy, and demonstrate that you care about their well- being.
• Use simple language: Avoid medical jargon and plain language that is easy for the patient and their
family members to understand.
• Practice active listening: Listen carefully to what the patient and their family members say. Encourage
them to share their feelings and concerns and validate their experiences.
• Be honest and transparent: Provide clear and accurate information about the patient's condition,
prognosis, and treatment options. Avoid withholding information or providing false hope.
• Respect cultural and spiritual beliefs: Take the time to understand the patient's cultural and spiritual
beliefs and respect their preferences for care.
• Collaborate with the healthcare team: Work collaboratively with other healthcare team members to
ensure that the patient's physical, emotional, and spiritual needs are met.
• Use appropriate body language: Use appropriate body language to convey empathy and
understanding, such as making eye contact and nodding in agreement.
• Ensure privacy and confidentiality: Ensure that the patient's privacy and confidentiality are
respected, and that sensitive information is not disclosed to others without the patient's consent
 Need for Effective Communication

1. Patient-centered care: Palliative care is focused on the patient's needs and goals, and effective
communication is crucial in understanding and addressing those needs and goals.
2. Quality of life: Palliative care aims to improve the patient's quality of life, and effective
communication helps healthcare providers to understand the patient's physical, emotional, social
and spiritual needs and tailor care accordingly 3. Decision-making: Effective communication is
essential for shared decision-making between the patient, their family members, and the
healthcare team. It helps ensure that decisions are made that align with the patient's
preferences and values.
4. Symptom management: Effective communication helps healthcare providers identify and
manage symptoms, such as pain and nausea, that can significantly impact the patient's quality of
life.
5. Emotional support: Palliative care is often a time of emotional distress for patients and their
families, and effective communication can provide emotional support and comfort. 6.
Coordination of care: Effective communication helps ensure that the patient's care is coordinated
across different healthcare providers and settings, such as hospitals, hospices, and home care
 Fail to communicate conseuence
• It may lead to poor symptom control.
• The patient may not follow the plan of care as their needs/agendas have not
been discussed and supported.
• The adjustment to the illness and interventions would be poor, and this can lead
to worsening distress.
• There can be situations with escalating conflict.
• The team that does not communicate effectively may find an enquiring patient
‘too demanding.’ This can affect the therapeutic relationship.
• Medico-legal problems stem primarily from poor communication, and
misperceptions and misunderstandings may ensue.
 Aims of effective communication in a
nurse
• Patient relationship
• Reduce uncertainty
• Enhance relationship
• Prevent unrealistic hope
• Allow proper adjustment
• Provide personal satisfaction
• Guide and give direction
 Communication skills
• Active listening: Nurses should listen attentively to patients, family members, and other
healthcare providers to understand their concerns, fears, and needs fully.
• Empathy: Nurses should be able to understand and relate to the emotions and feelings of their
patients and their families, providing comfort and support
• Clear and concise communication: Nurses should be able to communicate clearly and
concisely with patients and their families, using appropriate tone and language. They should also
use plain language to explain complex medical information.
• Non-verbal communication: Nurses should be aware of their body language, facial expressions,
and gestures, which can convey more information than words alone.
• Open and honest communication: Nurses should be open and honest with patients and their
families, discussing end-of-life issues, including pain management, palliative sedation, and
withdrawal of treatment.
• Culturally sensitive communication: Nurses should be aware of cultural differences and be able
to communicate effectively with patients and their families from diverse backgrounds.
• Conflict resolution: Nurses should be able to manage disagreements and conflicts between
patients, families, and healthcare providers in a respectful and constructive manner.
 Core Principles of Communication
• Respect: Respect involves treating others with dignity and recognizing their worth. It involves
valuing their opinions and ideas, even if they differ from our own. Respecting others' boundaries,
cultural backgrounds, and beliefs is critical in building positive relationships and fostering open
communication.
• Empathy: Empathy is the ability to understand and relate to the feelings, thoughts, and
experiences of others. It involves putting ourselves in another's shoes and seeing things from their
perspective. Empathy helps to build trust and strengthen relationships by demonstrating our
willingness to understand and support others.
• Trust: Trust is the foundation of all healthy relationships. It involves having confidence in others'
integrity, reliability, and ability to meet our expectations. Trust is built over time through consistent
and transparent communication and by keeping our commitments.
• Unconditional positive regard: Unconditional positive regard involves accepting and valuing others
for who they are, regardless of their thoughts, feelings, or behaviors. It involves seeing the good in
others and treating them with kindness and compassion. Unconditional positive regard helps to
create a safe and supportive environment where individuals feel accepted, valued, and respected.
Consequences of poor communication
1. Increased anxiety and distress: Patients and families may feel anxious, confused, and uncertain
about their medical condition, prognosis, and treatment options if they do not receive clear and
accurate information from healthcare providers.
2. Inadequate pain and symptom management: Poor communication between healthcare
providers may result in inadequate pain and symptom management, leading to increased suffering
and decreased quality of life for patients.
3. Reduced patient satisfaction: Poor communication can lead to reduced patient satisfaction and
trust in healthcare providers, potentially leading to patients and families seeking care elsewhere.
4. Conflict and disagreements: Poor communication can result in misunderstandings and
disagreements between patients, families, and healthcare providers, potentially leading to conflict
and ethical dilemmas.
5. Increased burden on family caregivers: Poor communication can result in family members
feeling unprepared and overwhelmed with the responsibilities of caregiving, leading to increased
stress and burnout.
6. Increased healthcare costs: Poor communication can lead to repeated hospitalizations,
unnecessary medical interventions, and increased healthcare costs
 Contd.,
1. Increased anxiety and distress: Patients and families may feel anxious, confused, and uncertain
about their medical condition, prognosis, and treatment options if they do not receive clear and
accurate information from healthcare providers.
2. Inadequate pain and symptom management: Poor communication between healthcare
providers may result in inadequate pain and symptom management, leading to increased
suffering and decreased quality of life for patients.
3. Reduced patient satisfaction: Poor communication can lead to reduced patient satisfaction and
trust in healthcare providers, potentially leading to patients and families seeking care elsewhere.
4. Conflict and disagreements: Poor communication can result in misunderstandings and
disagreements between patients, families, and healthcare providers, potentially leading to
conflict and ethical dilemmas.
5. Increased burden on family caregivers: Poor communication can result in family members
feeling unprepared and overwhelmed with the responsibilities of caregiving, leading to increased
stress and burnout.
6. Increased healthcare costs: Poor communication can lead to repeated hospitalizations,
unnecessary medical interventions, and increased healthcare costs
 Barriers to effective communication

• Professional versus social dialogue: Unlike social interactions, any form of professional dialogue
would have an implicit contract between the professional and the patient. This differentiation brings
forth a unique set of barriers and problems for professionals during communication with the patient.
• Professional problems in communicating with patients:
• Fear of upsetting the patient
• Fear of causing more harm than good
• Unsure about answering difficult questions
• Afraid of saying, “I don’t know.”
• Patient’s belief that health professionals are too busy
• Unable to manage patient’s emotions
• Unable to improve the situation
• Fear of the untaught
• Fear of being blamed
 Patient’s problems in communicating with
health professionals Patients
• Think that the health professionals are too busy.
• Think that they are more interested in their physical care.
• They do not want to know about any emotional problems.
• They are frightened to complain in case they stop treating them.
•They are frightened of going out of control.
• There may be terrified of having the truth revealed
 The problems arising in
communication
• Pretending to be busy
• Selective attention to safe physical aspects
• Not exploring beyond physical issues
• Premature/false reassurance
• Premature normalization
• Jollying along
• Inappropriately introducing humor
• Concentrating on physical tasks
• Using euphemisms to mislead
• Disappearing from the stressful situation
• Patronizing and talking down to patients
• Using medical jargon
 Examples of good and poor
communication techniques
1. Ask for open techniques! Nurse “Is your pain better today? This closed question gives
either a yes or no answer and needs revision.
Nurse: “How are you feeling?” This allows the patient to open up and vent their feeling.
2. Be empathetic Patient: “I feel scared when I am breathless.” Nurse: “Take these
tablets to ease your breathing”. Here, the nurse has ignored the patient's emotions,
which is wrong. The correct approach would be. Patient: “I feel scared when I am
breathless.” Nurse: “Breathlessness can be very frightening. It is very understandable. I
shall give you the prescribed medicines which should help you.” OR Nurse: “What
scares you most when you get breathlessness?”
3. Be sensitive while telling the truth Patient: “The doctor said my cancer is incurable.”
Nurse: “Don't worry about such things. Everything will be okay”. Here, the nurse is
giving false reassurance, which is not the correct approach. A better statement would
be as follows.
Contd.,
• Nurse: “It must have been tough to hear that cancer has spread, but we will do our best to
help you however we can.” 4. Always try to balance hope and truth Nurse: “There is nothing
more we can do; your disease is incurable, so there is no point in staying in the hospital.”
Here the nurse is destroying hope, which is incorrect. The nurse should try to balance hope
and truth. Nurse: “I am sorry that no more treatments are available to cure your disease, but
we can start other medicines to make you more comfortable. Then you can be at home with
your family. If you need any help in future, you must come to the clinic or contact me.” 5.
Keep confidentiality and avoid unhealthy curiosity Patient: I have not told anybody before,
but I got this cancer because I had an abortion when I was seventeen.” Nurse: “Were you not
worried at that time.” Here the nurse is getting curious about the irrelevant matter. The right
approach would be as Nurse: “We need to discuss this more, as it is incredibly significant for
you, but please know that everything we discuss will be kept confidential.” The nurse here
assures confidentiality, and at the same time, he would like to have more details which would
be medically significant. 6. Partnership between nurse and patient Nurse: “You must take this
medicine for your pain. Unless you accept this, your pain will remain as such. The nurse is
imposing their agenda on the patient, which is wrong. Nurse: “Your pain is caused by the
disease, and you need pain medicine. How about trying it?” Here the nurse is trying to set up
a bond with the patient by soliciting his opinion.
 Nonverbal communication
• Nonverbal communication is an important aspect of communication in palliative
care, as it can convey emotions, empathy, and understanding. Non-verbal
communication: Non-verbal communication is featured by mode and tone of voice
with which words are spoken; gestures going with the speech; looks and facial
expressions; physical contact, touch, body posture, pitch and pace of voice, and
active listening. Here are some examples of nonverbal communication in palliative
care
• Eye contact: Making eye contact with the patient and their family members can
convey empathy and understanding, and can help to establish a rapport.
• Facial expressions: Facial expressions, such as a smile or a nod, can convey
empathy, understanding, and support.
• Touch: Appropriate touch, such as holding a patient's hand or giving a hug, can
convey compassion and comfort.
• Body language: Body language, such as leaning forward or sitting at the same level
Contd.,
• Silence:.
• Tone of voice
• Environment
 Communicating with patients who have advanced and progressive diseases
in palliative care ntd.,
• diseases can be challenging, but it is essential for providing compassionate care. Effective communication
with patients facing progressive disease, with complex problems and an uncertain future, is challenging and
needs more skills and practice. Patients with advanced and progressive diseases have issues other than
physical, and they require compassionate listening and empathetic responses. Here are some tips for
effective communication:
• Use simple language: Use plain and straight forward language to ensure that patients can understand you
easily.
• Be honest: Be honest and transparent the patient's about condition, prognosis, and treatment options. •
Listen actively: Listen carefully to the patient's concerns and feelings, and encourage them to share their
thoughts.
• Show empathy: Show empathy and understanding the towards patient's emotional and physical challenges.
• Respect the patient's autonomy: Respect the patient's autonomy and allow them to make decisions about
their care to the extent that it is possible.
• Provide support: Provide support to patients and their families to cope with the changes that come with the
advanced and progressive stages of the disease.
• Collaborate with the healthcare team: Work collaboratively with other healthcare team members to ensure
that the patient's physical, emotional, and spiritual needs are met.
• Use nonverbal communication: Use nonverbal communication, such as touch, eye contact, and facial
• Avoid false hope: Avoid providing false hope or unrealistic expectations, and
instead focus on providing comfort and symptom management.
• Consider cultural and spiritual beliefs: Consider the patient's cultural and
spiritual beliefs when communicating and providing care. By using these
strategies, healthcare providers can communicate effectively with patients with
advanced and progressive diseases in palliative care and provide compassionate
care that meets their physical, emotional, and spiritual needs. Basics steps of
communication i. ii. iii. iv. i. Preparing for listening Questioning Listening
effectively (facilitating) shows that you have heard Responding Preparing for
listening It is essential to practice active listening as it is the key to effective
communication. Active listening: involves fully focusing on the speaker and
attempting to understand their message. This includes paying attention to the
speaker's verbal and nonverbal communication, asking clarifying questions, and
providing feedback. Active listening requires the listener to be fully engaged in
the conversation, to concentrate on what is being said, and to be present in the
moment. Active listening is important in palliative care, as it can help healthcare
providers to understand the patient's needs and concerns and provide
 Contd.,
• Passive listening: on the other hand, involves listening without actively engaging in the conversation. The listener
may appear to be listening but is not fully focused on the speaker's message. Passive listening may involve nodding,
making eye contact, or saying "mm-hmm" without really paying attention to the content of the message. Passive
listening can lead to misunderstandings, miscommunication, and missed opportunities for building rapport with
patients and their families. The following methods help to enhance listening skills.
• Greeting and seating: Allow the patient to take their comfortable position in the bed or chair. Provide privacy and sit
beside the patient at a reachable distance without any barrier between the patient and yourself.
• Ask open questions: Open-ended questions give freedom to the patient to decide what and how much they should
tell.
• Encourage talking: To get more details and develop better rapport, it is good to encourage the patient to talk about
his concerns.
• Maintain eye contact: It gives confidence to the patient that they are being actively listened to
. • Tolerate brief silence: Silence can have diverse meanings in communication. It can be understood as a time to think,
consider a response, or express emotion
• Avoid unnecessary interruptions: Interruptions should not be too frequent in a way that affects the flow of
communication.
• Show them that they are listened to: The patients should feel that they are being heard by verbal and non-verbal
means. This can be done by repetition, reiteration, and reflection.
• Summarize and prioritize the agenda: We must summarize and explain the treatment plan and help them with
shared decision-making.
 Questioning
• Questioning is an important aspect of communication that involves asking questions to gather information,
clarify understanding, and encourage dialogue. There are several types of questions that can be used in
communication, including:
1. Open-ended questions: These are questions that require more than a simple yes or no answer. They
encourage the speaker to provide more detailed information and can help to facilitate conversation and
encourage the exploration of thoughts and feelings. Example: "What brings you to palliative care today?"
2. Closed-ended questions: These are questions that can be answered with a simple yes or no. They can be
useful for getting specific information but may not encourage further conversation. Example: "Have you
experienced any pain today?
3. Leading questions: These are questions that are phrased in a way that suggests a particular answer. They
should be avoided as they can bias the response. Example: "You're not experiencing any pain today, are you?“
4. Clarifying questions: These are questions used to gain a better understanding of the speaker's message. They
can be useful for ensuring that the listener has understood the speaker's meaning. Example: "Can you explain
what you mean by 'feeling anxious'?“
5. Reflective questions: These are questions used to reflect back the speaker's message to show that the
listener has understood. They can be useful for building rapport and showing empathy. Example: "It sounds like
you're feeling overwhelmed by the situation. Is that correct?“
6. Hypothetical questions: These are questions used to explore potential future scenarios or situations. They
can be useful for decision-making and problem-solving. Example: "What would you like to do if your pain
becomes too difficult?"
 Contd.,
• In palliative care, open-ended, clarifying, and reflective questions may be
particularly useful for building rapport with patients and their families,
understanding their needs and concerns, and providing appropriate care. There
are several key principles of questioning in communication that can help to
promote effective communication: 1. 2. 3. 4. Use open-ended questions: Open-
ended questions allow the speaker to provide more detailed information and
encourage further conversation. They are useful for building rapport and
understanding the speaker's perspective. Avoid leading questions: Leading
questions suggest a particular answer and can bias the response. They should be
avoided in communication. Use clarifying questions: Clarifying questions help to
ensure that the listener has understood the speaker's message. They can be used
to gain a better understanding of the speaker's perspective. Use reflective
questions: Reflective questions reflect back the speaker's message to show that
the listener has understood. They can be used to build rapport and show
empathy.
 Contd.,
• Avoid interrupting: Interrupting can be seen as disrespectful and can hinder effective communication. It is
important to allow the speaker to finish their thought before responding. Be aware of nonverbal
communication: Nonverbal cues such as tone of voice and body language can impact the effectiveness of
questioning. It is essential to be aware of these cues and use them to guide the questioning process. Effective
questioning can help nurses to understand the patient's needs and concerns, provide appropriate care, and
build rapport with the patient and their family. It is important to use questioning techniques that are
respectful, empathetic, and focused on understanding the patient's perspective. iii. Listening effectively
(facilitating) shows that you have heard Listening effectively and facilitating a conversation involves more
than simply hearing the speaker's words. It involves actively engaging in the conversation, demonstrating
empathy, and providing feedback to show that you have understood the speaker's message. The listening
wheel can be followed to show that you are listening.
• Open Questions: How? What? Where? Who? Why?
• Summarizing: A summary helps to show the individual that you have listened to and understood their
circumstances and feelings.
• Reflecting: Repeating a word or phrase encourages the individual to continue and expand.
• Clarifying: Sometimes, an individual may gloss over a crucial point by exploring. These areas further, we can
help them clarify these points for themselves.
• Short Words of Encouragement: The person may need help to go on with their story – use words like ‘yes’ or
‘go on.’
• Reacting: We need to show that we have understood the situation by reacting to it “That it sounds like it is
Contd.,
 Benefits of effective listening
• Build trust and strong relationships
• Helps to resolve conflict
• Prevents missing valuable information

• Helps to build more knowledge iv. Responding Effective responding in palliative care communication is important
to ensure that the message is received and understood. Here are some key principles of responding in
communication:
• Acknowledge the message: Start by acknowledging the speaker's message to show that you have heard and
understood what they have said.
• Provide feedback: Provide feedback to the speaker to show that you are engaged in the conversation. This can be
in the form of nodding, making eye contact, or providing verbal cues such as "I see" or "I understand."
• Reflect on the message: Reflect on the speaker's message to show that you have understood their perspective. This
can be done summarizing what has been said or paraphrasing the message in your own words
• Show empathy: Demonstrate empathy by acknowledging the speaker's feelings and validating their perspective.
This can help to build trust and rapport.
• Respond appropriately: Respond appropriately to the speaker's message. This may involve providing information,
offering support, or asking further questions to clarify understanding
• Avoid interrupting: Avoid interrupting the speaker as it can be seen as disrespectful and can hinder effective
 Tips for responding to create a
supportive helping relationship
• Respond in a way that focuses attention on the issues and concerns: clarify inconsistencies and gather facts quickly
and unobtrusively.
• Probe with open–ended statements to gain more information. Use Tell me more about …, Let us talk about that, or
I'm wondering about … Responding in this manner is usually more effective than using specific who, what, when,
where, and why questions.
• Ask for clarification, e.g., I am having trouble understanding what you're saying. Is it that …? Or could you review
that again, please?
• Use understandable words. Listen to the vocabulary of the other person to get a clue to their level of
understanding.
• Try not to preach, blame, or be demanding.
• Try to avoid straying from the topic!
• Show understanding and sincerity in your responses, so the patient will feel comfortable discussing more
information.
• Try not to talk excessively about yourself. Keep self–disclosure to a minimum!
• Give responses proper for the age, sex, and emotional state of the patient!
 Effective communication
• In palliative care, effective responding is important to ensure that the patient's needs and
concerns are addressed, and that appropriate care is provided. It is important to use
responding techniques that are respectful, empathetic, and focused on understanding the
patient's perspective. By demonstrating empathy, active listening, and appropriate responses,
healthcare providers can promote effective communication and build trust with patients and
their families. What is not recommended during clinical communication?
• 1) Do not at once reply to the patient’s words. It is helpful to enquire about feelings or real
questions behind the patient words. E.g., When a patient asks… “Sister, how long do I have?”
the implicit question usually is “Sister…now that I have very little time left, what can I expect?
How can you help me?”
• 2) Do not use philosophies or moralize. They may hurt the patient’s feelings and stop the
further conversation. E.g., “You should not say such things. God gave your life. Trust in God.”
• 3) Avoid comparisons. It is insensitive to say that someone else’s grief is more significant;
therefore, the patient has no right to grieve. E.g., “Look at that man over there. He has no
family; he is alone and in pain. At least be thankful that you have a loving family.”
• 4) Avoid meaningless words. E.g., “There is nothing to be afraid of.” 5) Avoid medical words.
They are jargon from the patient’s point of view. Technical language tends to overwhelm
patients
 Contd.,
• 6)Avoid false reassurance. E.g., "When your general health improves, we shall try more
chemotherapy. That will cure you.” It does not provide comfort, and it destroys trust. Reassurance
is essential to keep hope after due interactions and explanations, but it must be based on truth.
• 7) Do not make assumptions. Check the patient’s insight about the diagnosis and prognosis and
what it means to her. E.g., “What made you ask that question?”
• 8) Avoid a condescending attitude. The patient will be open to you only if you deal with them
respectfully.

• 9) Do not force your beliefs or convictions on the patient. E.g., “You must regularly chant for
strength to endure this” is imposing your beliefs on a patient.
• 10) Avoid sympathy, which is hard to bear. E.g., “Oh, you unfortunate thing; it is so sad you must go
through this terrible disease.” Instead, convey empathy – an attempt to put us in the patient’s
shoes and understand what he is going through. E.g., “I can see that you are going through a lot….”
• 11) Avoid inappropriate humour. E.g., “You are waiting for your final Visa? Ha, ha!”. The patient
himself may use humour as a coping strategy, but coming from us, it may seem insensitive.
• 12) Avoid both lies and thoughtless honesty. Lies may not be believed; even if accepted, they will
destroy trust later. Also, the truth should not be disclosed like a bombshell. Truth is a powerful
 COMMUNICATING BAD NEWS
• Breaking bad news (BBN) refers to the process of delivering information to a patient, family
member, or caregiver that may be distressing or difficult to hear. This can include news about a
serious illness, a poor prognosis, a treatment failure, or other negative developments related to
the patient's health. BBN is a challenging aspect of palliative care, as it can be emotionally
difficult for both the patient and the healthcare provider. BBN is essential to communication as
it takes time for the patient to accept the truth. It needs to be discussed in detail and clarified
when more information is shared. It can significantly impact the patient's emotional well-being
and ability to make informed decisions about their care. It requires empathy, sensitivity, and
effective communication skills to ensure that the patient and family members receive the
information they need to make informed decisions and cope with the emotional impact of the
news We need to analyze ourselves beforehand
• Should we tell the diagnosis to the patient or not?
• If you were diagnosed with cancer, would you want to be told?
• How would you feel if your family hid the news from you? Why should patients be told about
their disease?
• The patients have the right to know about their disease.
Contd.,
• Breaking Bad News Breaking bad news is an essential part of healthcare, but it can be a challenging and emotional
experience for both patients and healthcare providers. Here are some steps to follow when breaking bad news:
1. Prepare for the conversation: Before you start the conversation, prepare yourself mentally and emotionally.
Review the patient's medical history and any relevant test results, and anticipate their potential reactions and
questions.
2. Choose an appropriate location: Choose a quiet and private location where you can talk without interruption or
distractions. Make sure the patient is comfortable, and offer them a glass of water or tissues if necessary.
3. Set the tone: Begin the conversation with empathy and compassion. Be direct but compassionate, and avoid
medical jargon. Ask the patient if they would like a family member or friend present during the conversation.
4. Deliver the news: Use clear and simple language to explain the diagnosis and the implications. Allow time for the
patient to process the information and ask questions. Provide information about treatment options, potential
outcomes, and support resources.
5. Address emotions: Acknowledge the patient's emotional reactions and offer reassurance and support. Allow them
to express their feelings and concerns, and validate their emotions. Offer resources for emotional support, such as
counseling or support groups.
6. Develop a plan: Work with the patient to develop a plan of care that aligns with their goals, preferences, and
values. Involve the patient in decision-making, and offer choices whenever possible. Set realistic expectations, and
provide ongoing support and communication.
7. Follow up: Follow up with the patient and their family after the conversation to answer any remaining questions,
 COLLUSION
• The act of shielding information from the patient or family is called collusion.
Collusion in palliative care refers to the situation where healthcare providers and
the patient or family members avoid discussing difficult topics such as end-of-life
decisions, prognosis, or treatment options. This collusion can occur for various
reasons, including the healthcare provider's fear of causing distress to the patient
or family, a lack of communication skills or training, or the patient or family's
reluctance to face the reality of the situation. Collusion in palliative care can have
negative consequences for the patient and their loved ones, and it's important for
healthcare providers and caregivers to prioritize open and honest communication
and respect the patient's autonomy and wishes. Collusion = “PLEASE DON’T
TELL” Collusion implies information (about diagnosis, prognosis, and medical
details about the patient) being held by some and kept from significant
stakeholders. The type of professional care team treating the patient and colluding
with the family members is a frequent problem. In addition, withholding of
information also occurs between the professional team and the patient.
Contd.,
• This occurs when family members or caregivers work together to withhold
information from the patient or make decisions without the patient's input. This
can happen when family members feel that they know what is best for the
patient, or when they believe that the patient cannot handle bad news.
 Consequences of collusion
• The patient lacks trust in everyone close to them, including the professional team • Unfinished
business for the patient or family members
• Chronic anger • Depression and suicidal tendencies
• Disturbed sleep patterns
• Disturbed eating patterns
• Disturbed leisure patterns
• Disturbed conversation patterns All these factors can result in the patient losing control and entering
a stage of chronic depression resulting in weakness, weight loss, and disability. Managing collusion
• Acknowledge with family members that a collision exists.
• Speak reassuringly, for instance, by saying, “you know your brother much better than I do.” •
Empathize with the difficult position the family member is in. For instance, one could say, “It must be
challenging for you to maintain secrecy with the patient,” or “I guess you don’t normally keep
important things from your brother.” • Empathize again and as often as possible to gain the family
member’s trust. • Empathizing and asking a dire question. One could say, “What effect does this have
on you?’ Effect of Collusion Collusion creates an atmosphere of suspicion, poor communication, and
poor relation between the patient and his family members. One is never able to remain honest. This
situation gets worse as time goes by for both professional team members and family members.
Contd.,
• The effects of collusion in palliative care can be particularly harmful, as patients and families rely on
healthcare providers to be open and honest about their condition and treatment options. Here are some
of the effects of collusion in palliative care:
• Lack of informed decision-making: When healthcare providers collude, patients and families are denied
the information they need to make informed decisions about their care. This can lead to decisions being
made based on incomplete or inaccurate information, potentially resulting in treatments that are
ineffective, unnecessary, or harmful.
• Loss of trust: Collusion can erode trust between patients, families, and healthcare providers. When
patients and families discover that healthcare providers are not being honest with them, they may become
suspicious of their motives and lose confidence in their ability to provide effective care.
• Increased emotional distress: Collusion can increase emotional distress for patients and families. When
patients and families are not given the information they need to understand their condition and treatment
options, they may experience feelings of confusion, anxiety, and mistrust.
• Worsened quality of life: Collusion can negatively impact the quality of life for patients and families by
limiting their ability to make informed decisions about their care. Patients may receive treatments that are
not aligned with their values, preferences, and goals, resulting in decreased quality of life and increased
suffering.
• Legal and ethical implications: Collusion in palliative care can have legal and ethical implications, as
patients have the right to be fully informed about their condition and treatment options. Healthcare
Contd.,
• ANGER Anger is a common emotion experienced by patients in palliative care, as well as their
families and caregivers. Anger is a response to feelings of helplessness, distress, and fear. It
may also be a negative result of ineffective communication between healthcare professionals
and the patient/carer/ family members. Anger is often unleashed on a person perceived as
close (like a spouse, close friends, or close family members) or non - threatening (usually
security staff, reception staff, attenders, junior nurses, and junior doctors). It's important to
acknowledge and address anger in a compassionate and empathetic manner to ensure that
patients and their loved ones feel heard and supported. There are several reasons why
patients and their families may experience anger in palliative care, including:
• Loss of control: Patients and their families may feel like they have lost control over their lives,
as they may not be able to make decisions about their care or may have to rely on others for
assistance.
• Fear and uncertainty: Palliative care often involves uncertainty about the future, which can be
frightening and overwhelming for patients and their families.
• Unresolved issues: Patients and their families may have unresolved issues related to their
illness or past experiences, which can lead to anger or resentment.
• Pain and discomfort: Physical pain and discomfort can also contribute to anger and frustration
 Approach to Anger
• The patient may direct anger at you irrespective of whether you are the source of
distress. Acknowledge and name the emotion. Then address the need of the
patient to be understood. E.g., “I can see that you are angry; can we sit down and
talk…. tell me what you thought went wrong… I may be able to help you.”
• Be calm and empathetic and use positive non-verbal throughout the
conversation.
• Give the patient time to express himself.
• Allow the patient to express his emotions/feelings.
• Observe the nonverbal cues of the patient.
• Acknowledge the reasons for anger.
• Arrive at a consensus through ‘participatory decision-making.’
• Summarize the conversation.
• Ask if the patient wants to add something or needs any clarification.
 DENIAL
• Denial is the patient’s refusal to take on board the bad news. It is avoiding thoughts and feelings that are painful or that you
cannot deal with. It occurs to some degree in everyone who has a serious illness. It is a shock absorber that helps you bear an
overwhelming situation and cope with it. However, for some patients, denial of the illness or its severity can cause delayed
diagnosis or compromised compliance with treatment. In that event, patient and sustained efforts may be required to convey
at least one part of the truth to permit treatment. Denial can be a problem if the patient:
• Does not accept the diagnosis and /or prognosis and avoids/delays treatment.
• Minimises the symptoms and implications of the illness.
• Insists on continuing with curative treatments and other measures which have been proven futile/ineffective. Denial is a
common defence mechanism in most palliative care patients. It varies in severity and pervasiveness. It has varying effects on the
process of adaptation. In some cases, denial reduces anxiety, while, in others, it results in excessive delay in seeking help and
poor compliance to treatment. Questions that may give an idea about the nature of denial.
• What do you think about your illness?
• What is your understanding of the seriousness of your illness?
• What are your plans?
• Do you have another plan (Plan B) if the former is found to be not working? Assessment of denial
• A cognitive evaluation is essential to rule out the possibility of any psychiatric disorders.
• Check the patient’s insight – set up what they know. This should include their understanding of the diagnosis, prognosis, and
current treatment regime.
• Listen to the words used and observe the non-verbal communication when the patient narrates. This will tell you how much
the patient knows or how he feels about the illness. Approach to Denial
• Ensure that the patient’s denial is not due to a lack of information, understanding, or agreement
Contd.,
• with medical recommendations. • Distinguish between a fact being denied (e.g.,
diagnosis of cancer) and implications of the fact denied (e.g., cancer will not
return). • Assess how and when the patient uses denial. • Assess the benefits
and risks of denial to the patient’s psychological condition and compliance with
treatment. • If the denial is expressed by minimization of illness or lack of
emotional response, it signals that the patient is frightened. Provide emotional
support and discuss their issues/concerns.
• • Adopt a non-confrontational approach. If the denial is causing significant
problems, confrontation may only increase the use of denial. • Finally,
emphasize to patients that they will not be abandoned. They will be supported
and cared for
 NURSING MANAGEMENT OF
SYMPTOMS
Introduction :-Patient descriptions of physical symptoms and their severity are the
primary data for symptom assessment in palliative care. Exploring patients' reports
of symptoms requires thoroughness, persistence, and patience, a fundamental
aspect of palliative care. Symptom assessment usually involves taking a detailed
history from the patient to understand the cause and severity of the symptom.
Ideally, the management should be guided by a comprehensive assessment of
symptoms subjectively and objectively. This helps us evaluate the significance of
symptoms on patients' distress, quality of life, and survival. Effective symptom
management aims to provide comfort and can potentially increase the quality of
life for patients and families.
Holistic approach in symptom assessment and management Holistic care focuses on the whole
person, not just the condition. It looks at how the individual is dealing with the situation, their
physical, psychological, social and spiritual domains of health and any issues they are experiencing.
Integrating holistic/palliative care principles into routine nursing practice at the hospital and home
care makes it possible to provide patients and their families with high-quality care. Symptoms are
inherently subjective; hence, self-report must be the primary source of information. Detailed history-
taking is important. The assessment of symptoms is a vital aspect of nursing care to provide comfort
and enhance the quality of life. Principles of Symptom
Assessment and Management
Anticipate needs: A proactive and systematic approach to symptom assessment can help anticipate
patients’ clinical needs and support care management.
Assess and manage holistically: Consider which problems most affect the person’s quality of life
(physical, emotional, social and spiritual). Many symptoms are multifactorial, or occur in clusters, and
some causes may be more or less reversible than others.
Manage pre-emptively: Given the nature of this persons’ disease, consider what problems may need
to be planned for, and ensure that essential medications can be accessed when needed so that the
symptoms continue to be managed. To avoid delays for example over a weekend, it is advisable to
indent and ensure that medication is available within the facility prior to its being needed. This pre-
Contd.,
Assess and reassess frequently: Consider using simple assessment tools like the
Symptom Assessment Scale (SAS) - to screen for and monitor symptoms. Check for
adverse effects of treatments, as well as benefits, regularly. Assess whether
problems are likely to be due to reversible or irreversible causes. Consider and
discuss the likely burden of various treatment options (cost, difficulty of
undergoing investigations, realistic improvement that might be expected
etc.).Consider both pharmacological and non-pharmacological management
options.
 SYMPTOM ASSESSMENT SCALE (SAS)
• Timely referral: If a problem does not respond to primary care management, or is complex, refer to specialist
palliative care for further advice. The key points in managing symptoms are as follows:
1. Base the care components on the patient’s idea of the quality of life.

2. Follow the five “A” s of chronic care – “Assess, Advice, Agree, Assist, Arrange.”
3. Correct the correctable contributory factors.
4. Involve the multidisciplinary team to address the care needs in all dimensions physiotherapist, psychologist,
nutritionist, medical social worker, occupational therapist, yoga therapist etc. Use non-pharmacological as well as
pharmacological treatment.
5. For any continuous pain, analgesia is better achieved with round-the-clock administration of analgesics rather
than giving them SOS basis.
6. Keep the treatment regimen as simple as possible for the patient.
7. A formatted prescription with names of drugs, the reason for the use, dose and timings is more advisable than
verbal advice.
8. Seek expert’s advice in intractable situations.
9. Avoid false re-assurances yet maintain realistic hope.
10. Prioritize concerns from the patient’s point of view.
 General guidelines for all nurses
1. Listen attentively. Be a good listener.
2. Do not consider the patient's problems insignificant.
3. Do not force your opinions/beliefs upon the patient.
4. Do not ignore the patient's queries.
5. Try not to give any false hopes.
6. Ensure confidentiality.
 PAIN

• Pain is an unpleasant feeling, such as a prick, tingle, sting, burn or

ache. Pain is what the person says, "it hurts".
Definition: “An unpleasant sensory and emotional experience
associated with, or resembling that associated with actual or potential
tissue damage
”- International Association for the Study of Pain (IASP) Concept of
pain: Pain is always a personal experience that is influenced to varying
degrees by biological, psychological, and social factors. Through their
life experiences, individuals learn the concept of pain. Pain cannot be
inferred solely from activity in sensory neurons.
 Assessment and Documentation of Pain
• Assessment and documentation of pain are essential for evaluating therapy efficacy, for a better
understanding of the pain, for encouraging and supporting the patient and for future reference. A
comprehensive pain assessment will allow for determining the causes related to psychosocial
factors, quality of pain, quality of life and functional status. Such an assessment should include
the location of pain, intensity, characteristics, mechanisms, expressions and functions,
assessment of the psychosocial factors and the current analgesic treatment, and the response to
the same. Assessment of a patient's pain requires a structured approach, good listening, and
observation skills with constant re-evaluation. The assessment could get challenging if the
patient experiences more than one type of pain. There are many approaches to assessing pain,
and each professional will develop his/her approach to the history of pain. It is important to
keep in mind an outline scheme for assessment with which you are confident. Assessing pain •
Seek to establish a relationship with the patient.
• Encourage the patient to do most of the talking.
• Begin with a wide - angle open question before on focusing and clarifying specifics.
• Watch the patient for clues regarding the pain.
• Avoid jumping to conclusions. Pain assessment tools need to be valid, reliable and relevant.
 PQRST of pain
• A good understanding of the patient's pain forms the keystone of the
development of a treatment plan. If not well controlled, pain can
interfere with every aspect of the patient’s daily life from their ability to
carry out simple activities of daily living, such as washing and dressing,
to their tolerance of other treatments. Inadequate pain assessment is an
important contributing factor to the under-treatment of pain.
Assessment of pain is complex because pain is always subjective. The
patient’s self-report of pain is the single, most reliable indicator of pain.
The basic principle in the assessment of pain is that the clinician must
accept the patient’s self-report of pain. Using pain diagrams to
document the pain at each visit is a good practice.
Contd.,
• P = Provokes/Precipitating/Palliating • What causes pain? • What makes it better?
• What makes it Worse? • What previous treatment have you tried to relieve your
pain? • Were they effective?
• Q = Quality • What does your pain feel like? • What words would you use to
describe your pain? • Is it sharp? • Dull? • Stabbing? • Burning? • Crushing? (Try
to let the patient describe the pain)
• R = Radiates • Where does the pain radiate? • Is it in one place? • Does it go
anywhere else? • Did it start elsewhere and now localized to one spot?
• S = Severity • On a scale of 0 to 10, with 0 being no pain and 10 being the worst
pain you can imagine, how much does it hurt right now? • How much does it hurt
at its worst? • How much does it hurt at its best? (This is a difficult one as the
rating will differ from patient to patient.)
• T = Time • When did your pain start? • How often does it occur? • Has its intensity
changed? • How long does it last?
 Types of pain scale
i. Multidimensional: Multidimensional scales explore all dimensions of
pain. Since they take time to administer, multidimensional pain scales are
not suitable for use in busy outpatient settings.
ii. Unidimensional: Unidimensional scales assess the overall intensity of
pain. These take little time to administer and hence are suitable for busy
clinical settings. Any one of the following scales can be used.
a) Numeric Rating Scale (NRS): This is the most commonly used pain
scale. The patient needs to rate the intensity of their pain on a scale of 0
to 10. Zero means no pain, while 10 stands for severe pain. This scale is
commonly used for persons above the age of 10 years.
SYMPTOM ASSESSMENT SCALE (SAS)
Contd.,
• Visual Analog Scale: Visual Analog for Pain consists of a horizontal (or vertical)
line. The left end of the line signifies no pain, which is depicted by a smiling face,
while the right end signifies the worst possible pain with a frowning face. This
visual depiction of pain levels helps patients communicate their pain intensity. As
the intensity of pain in VAS is majorly depicted with images of facial expression,
it can be used on a wide range of patients, including little children and elderly
people who might not be accustomed to using other pain scales such as the
Numerical Rating Pain Scale:- It is much easier for any patient to express their
perception of the intensity of their pain on VAS rather than converting it to a
number as required in the Numerical Pain Scale. The patient can simply mark a
spot on the scale that they feel represents their current state of pain.
c) Wong-Baker Faces Pain Scale (Observation scale for kids): The rating in
Wong-Baker pain scale is similar to the numerical rating but it combines pictures
with the number for the rating of the pain. This scale can be used even for children
as they can point to the face that depicts their intensity of pain.
Contd.,
Nociceptive Pain This refers to pain resulting from the stimulation of peripheral nerves. Pain
impulses enter the spinal cord through the dorsal horn and ascend to higher centers in the brain.
Inhibitory impulses block transmission at the spinal cord- dorsal horn, preventing transmission of
the impulses. Neuropathic Pain Neuropathic pain is pain arising from damage to the peripheral or
central nervous system. Clinical presentations include sensations such as burning or stabbing in
areas of sensory loss. Central pain refers to neuropathic pain caused by damage within the central
nervous system. There is usually an area of altered sensation incorporating the area of pain. A
cerebrovascular accident or spinal cord damage may be associated with central pain. Neuropathic
pain could be of different forms, such as:- Sympathetic-mediated pain is a relatively uncommon
form of neuropathic pain due to sympathetic nerve injury. Essential features are pain (often with
burning sensation) and sensory disorder related to a vascular as opposed to a neural distribution.
Such a problem is also associated with reduced sweating and dry shiny skin.
• Hyperalgesia – An increased response to painful stimuli.
• Allodynia – A painful response to stimuli such as light touch that does not usually cause pain
• Phantom limb pain - Phantom limb pain is a condition in which a person experiences pain or
other sensations in a limb that is no longer present. This phenomenon is most commonly
experienced by amputees, as it occur after a nerve injury or other trauma that results in the loss of
 Chronic pain

• Chronic pain refers to pain that persists for more than three to six
months, beyond the expected healing time. Various underlying
conditions, such as arthritis, fibromyalgia, nerve damage, or a past
injury can cause it. Chronic pain can significantly impact an
individual's physical, emotional,and social well-being, affecting their
quality of life, sleep, mood, and ability to work and engage in
activities.
 Management Principles
By the clock: Prescribe round- the- clock doses in contrast to SOS doses for effective pain relief. By the
mouth: Start with oral immediate-release opioids, titrate to an effective dose before switching to sustained-
release opioids. By the ladder: Medications should be provided according to the severity of the pain.
WHO LADDER FOR PAIN MANAGEMENT The WHO Pain Ladder is a set of guidelines for the
management of pain, developed by the World Health Organization (WHO) in 1986. It is a widely accepted
approach for the treatment of pain in patients, particularly those with cancer.
The WHO Pain Ladder consists of three steps, each of which corresponds to a different level of pain
severity:
Step 1: Non-opioid analgesics, such as Paracetamol and Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs), are used for the management of mild to moderate pain.
Step 2: If the pain is not adequately controlled with non-opioid analgesics, weak opioids such as Codeine
or Tramadol can be added to the treatment regimen.
Step 3: If the pain is still not adequately controlled with weak opioids, strong opioids such as Morphine
are added to the treatment regimen. Strong opioids are used for the management of severe pain. The WHO
Pain Ladder is designed to be flexible and can be adapted to the patient's individual needs. For example, a
patient with moderate to severe pain may begin treatment with a weak opioid instead of a non-opioid
analgesic, depending on their level of pain and individual circumstances. Overall, the WHO Pain Ladder
provides a framework for the management of pain that is widely used and has been shown to be effective in
improving the quality of life for patients with pain.
• WHO Analgesic Ladder Once the patient is started on the analgesic ladder, they must be reviewed regularly to
titrate the exact dose requirements and to assess for side effects, change in pain quality etc. • STEP I: (MILD PAIN)
Non-opioid (Paracetamol), NSAID (Diclofenac or Ibuprofen)
• STEP II: (MODERATE PAIN) Weak opioids like Codeine, Tramadol
• STEP III: (SEVERE PAIN) Strong Opioids like Morphine, Fentanyl, Buprenorphine NSAIDs (Non-Steroidal Anti-
Inflammatory Drugs) NSAIDs exert an anti-inflammatory action by inhibiting prostaglandin synthesis. Commonly
recommended NSAIDS are Ibuprofen, Diclofenac etc. Elderly patients or those with a history of peptic ulcers may be
more at risk of getting side effects. A proton pump inhibitor such as Omeprazole has been shown to reduce this risk.
Different NSAIDs have different reported relative risks. Ibuprofen has the safest side effect profile among traditional
NSAIDs.
• Headache due to raised intracranial pressure may be semi-resistant to opioids. It is, therefore, better to try
paracetamol. If necessary, these can be given rectally (paracetamol, naproxen or diclofenac) or subcutaneously
(diclofenac or ketorolac).
• NSAIDs that can be used for pain relief: Drug Acetaminophen Typical starting dose 650mg x 4hrly Ibuprofen 200-
800mg x 6hrly Diclofenac Sodium 50-75mg x 8-12hrly Naproxen 250-750mg x 12hrly Piroxicam 10-20mg daily
Ketorolac 10 mg qid Table 3.2: NSAIDS Adverse effects of NSAIDs Continued use of NSAIDs may cause damage to
the gastrointestinal, hepatic, renal system and interfere with platelet function. The symptoms may include nausea,
heartburn, dyspepsia, gastrointestinal (GI) bleeding, and ulcers. The risk of GI events with NSAIDs increases with 
Increasing dose of NSAIDs  Increasing age  NSAIDs used in combination with Aspirin -NSAIDs /Aspirin taken
with alcohol
 OPOIDS
• These drugs are best given by the oral route and the dose is tailored to suit each individual’s
needs instead of trying to give the standard dose. The dose of Morphine varies from patient to
patient. There is no set maximum dose or ceiling effect for morphine. An expert will
administer high doses after appropriate titration against pain. Alternate routes of administration
when oral administration is not possible for some reason are rectal, subcutaneous,
intramuscular and intravenous. The risk of addiction with the use of opioids is small and has
been traditionally exaggerated. Morphine and other opioids should not be withheld for fear of
addiction when the patient requires a stronger analgesic. Commonly used opioids for pain
relief: Step II Weak Opioids (Oral) Usual starting dose Codeine phosphate 10 – 15 mg x 4hrly
Tramadol hydrochloride 50mg x 6hrly Step III Strong Opioids (Oral) Morphine Sulphate
(oral) 5 – 10 mg x 4hrly 30 – 60 mg x 12hrly (sustained release) Oral Morphine Morphine
administered by mouth or oral route is the choice for cancer pain. It is administered as tablets
(i.e., 10 mg, 20 mg) or as aqueous solutions. Basics of Morphine use:
• There is no standard dose or upper limit for chronic cancer pain. The correct dose is that which
controls pain with minimal side effects.
• The dose is to be titrated for each patient.
• A laxative and anti-emetic for constipation and nausea/vomiting must always be given with
 Myths about Morphine
• Used only for patients with cancer
• Use only when the end of life is near\
• Can cause addiction/dependence
• Can cause respiratory depression
• Can’t be used for children Guidelines for starting a patient on Oral Morphine
1. Oral Morphine is indicated in patients with pain who do not respond to the
optimized combined use of a non-opioid and a weak opioid.
2. If the patient takes two or more PRN doses in 24 hours, the regular dose should
be increased by 30-50% every 2-3 days.
3. Prescribe stimulant laxatives. Adjust the dose as necessary. Constipation may be
more difficult to manage than pain.
4. Warn patients about the possibility of initial drowsiness.
5. For outpatients, write out the drug regimen in detail with time, name of drug and
6. Ordinary (normal/ immediate release) Morphine tablets or solution • Morphine is given q4h regularly ‘by the
clock’ doses of an equal amount.
• After 1-2 days, adjust the dose upwards if the patient still has pain or uses two or more SOS doses per day. •
Continue q4h regularly.
7. A double dose at bedtime obviates the need to wake the patient up for a 4 hourly dose in the early morning.
Morphine - what to be careful about? The following details should be kept in mind before starting a Morphine
treatment regimen:
o Painkillers such as Morphine may be taken regularly if the cause of the pain has not been treated and cured. The
effect of Morphine wanes in about four hours. Hence it has to be taken every four hours.
o A double dose may be taken at night in order to avoid waking up from sleep to take the medicine. o Morphine
does not cause acidity or heartburn, so it can be taken before or after food.
o Morphine induces constipation. Therefore, the medicine for constipation has to be taken along with Morphine on
the doctor's direction.
o Morphine may induce vomiting initially in some patients. However, vomiting may not last with the normal
Morphine course of a week or more. It is advisable to take medicine to control vomiting while starting a Morphine
regimen.
o If the patient is drowsy or delirious after taking Morphine, it could be due to an overdose. Stop the next dose and
inform the doctor. The same is to be adopted if the vomiting is severe or if there is a urinary blockage.
• Management of opioid overdose and side-effects Patients should be warned of the possible side
effects of Morphine, such as nausea and drowsiness that is usually temporary and often not a
problem. If sleepiness continues for a few days, other possible causes, such as uremia,
hypercalcemia or toxicity from other medications, should be excluded. Constipation is predictable,
and most patients need prophylactic laxatives. If toxicity occurs, reduce the Morphine dose. The
patient may need to miss several doses. Restart at a lower dose. Side effects of opioids
• Constipation: Stepwise escalation of oral stimulant (Tablet Bisacodyl 10 mg HS increased to TDS)
or if needed, an osmotic laxative (Syrup Lactulose) on opioid initiation.
• Nausea and vomiting: Usually self-limiting within 1 week. Prescribe Tablet Metoclopramide 10 mg
TDS or Tablet Haloperidol 1.5-2.5 mg HS.
• Drowsiness: Initial drowsiness may be a sign of effective pain relief in a sleep-deprived patient.
Stimulants such as Dextroamphetamine or Modafinil may be helpful if sedation 58 persists.
• Delirium: Assess for reversible causes like hypercalcemia and UTI. If no other cause is apparent,
consider Haloperidol 2.5-5 mg HS/PO.
• Myoclonus: May respond to Benzodiazepines but may be a sign of opioid toxicity requiring
hydration, opioid dose reduction or switching.
• Pruritus and Sweating: Try opioid rotation or 5HT3 antagonists (e.g. Ondansetron, Granisetron)
 Common symptoms of Morphine toxicity
• Morphine toxicity are myoclonic jerks, over-drowsiness (difficult to arise), hallucinations
and confusion. Patients with renal impairment are at high risk of developing Morphine
toxicity as the metabolites are excreted in the urine. If toxicity is observed, the drugs
should be discontinued immediately. The patient may have to miss several doses for the
toxic symptoms to disappear and should be started with the much lower dose and may
require spacing 6th hourly, 8th hourly etc. Signs of Overdose
• Drowsiness
• Delirium
• Myoclonus
• Respiratory depression (Very rare)
Use of Naloxone: Respiratory depression due to oral Morphine is rare, although the
incidence can increase when Morphine is given intravenously. Indications:
• Respiratory rate < 8 breaths/minute, difficult to arouse the patient and clinical evidence
of cyanosis. OR
 Use of Naloxone:
• Respiratory depression due to oral Morphine is rare, although the incidence can
increase when Morphine is given intravenously. Indications:
• Respiratory rate < 8 breaths/minute, difficult to arouse the patient and clinical
evidence of cyanosis. OR
• Respiratory rate 10-12 breaths/ minute, difficult to arouse and oxygen saturation
 Management of Neuropathic Pain
• The drugs used for Neuropathic Pain are considered as Adjuvant analgesics (Co-
analgesics). It is a drug, which is not an analgesic in its prime function but can
enhance pain control in combination with an analgesic. E.g., anti-emetics, anti-
depressants, anti-convulsant, muscle relaxant, antispasmodic, antibiotics,
anxiolytics and antacids.
1. Adjuvant drugs Adjuvant drugs are used in addition to analgesics in pain relief.
Adjuvants may belong to one of two categories
– • Drugs used to limit the side effects of analgesics
• Co-analgesics useful in certain types of pain
Along with drug therapy, it must be ensured that the patient’s activities are
analyzed, and those precipitating pain are avoided or reduced. Non-
pharmacological measures like hot pads, relaxation, and music therapy may also be
tried.
2. Tricyclic Antidepressants The mechanism of analgesic action occurs principally
by the facilitation of descending inhibitory pathways. E.g., Amitriptyline,
Imipramine. Lower doses than the dose commonly required for depression will be
effective in neuropathic pain. Other less sedating tricyclic antidepressants may be
more useful for certain patients.
3. Anticonvulsants Carbamazepine tends to result in more side effects, mainly
when combined with other drugs. Build up doses slowly to minimize adverse
effects. Gabapentin is the only anticonvulsant licensed for treating neuropathic
pain. Reported results with Gabapentin show that it is as effective as other
anticonvulsants but may have fewer associated side effects and it is more
expensive.
4. Anesthetic Agents Ketamine: An anesthetic agent causes dissociative
anaesthesia and has shown to be analgesic at sub anaesthetic doses.
5. Other Drugs Topical Lignocaine / Bupivacaine: It may be useful for superficial
localized areas of pain such as fungating wounds for short periods. Prolonged use
may lead to skin sensitization. Although the systemically absorbed dose will be
small, care should be exercised with patients susceptible to cardiac problems.
Capsaicin: Capsaicin cream (0.75%) may be used for the pain from post herpetic
neuralgia. Capsaicin is a derivative of chilli pepper and must be applied 4-5 times a
day after wearing gloves
Nursing interventions for the management of pain
• Assess pain characteristics using PQRST of Pain
• Assess for signs and symptoms associated with chronic pain such as fatigue, decreased appetite, weight loss,
changes in body posture, sleep pattern disturbance, anxiety, irritability, restlessness, or depression.
• Assess the patient's perception of the effectiveness of methods used for pain relief in the past.
• Evaluate gender, cultural, societal and religious factors that may influence the patient's pain experience and
response to pain relief.
• Assess the patient's expectations of pain relief.
• Assess the patient's attitudes toward pharmacological and non-pharmacological methods of pain management.
• For patients taking opioid analgesics, assess for side effects, dependency, and tolerance.
• Assess the patient's ability to accomplish activities of daily living, instrumental activities of daily living, and
demands of daily living.
• Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic
pain.
• Acknowledge and convey acceptance of the patient's pain experience.
• Provide the patient and family with information about chronic pain and options available for pain
management.
• Assist the patient in making decisions about selecting a particular pain management strategy.
Cold applications: Cold reduces pain, inflammation, and muscle spasticity by
decreasing 60 the release of pain-inducing chemicals and slowing the conduction
of pain impulses. This intervention requires no special equipment and can be cost-
effective. Cold applications should last about 20 to 30 minutes.
Heat applications: Heat reduces pain through improved blood flow to the area and
reduction of pain reflexes. This is a cost-effective intervention that requires no
special equipment. Heat applications should last no more than 20 minutes. Special
attention needs to be given to prevent burns with this intervention.
Massage of the painful area: Massage interrupts pain transmission, increases
endorphin levels, and decreases tissue oedema. This intervention may require
another person to provide the massage.
Contd.,
Progressive relaxation, imagery and music: These centrally acting techniques for
pain management work by reducing muscle tension and stress. The patient may
feel an increased sense of control over his or her pain. Guided imagery can help
the patient explore images about pain, pain relief, and healing.
Distraction: Distraction is a temporary pain management strategy that works by
increasing the pain threshold. It should be used for a short duration, usually less
than 2 hours at a time. Prolonged use can add to fatigue and increased pain when
the distraction is no longer present.
Acupressure: Acupressure involves finger pressure applied to acupressure points
on the body. Using the gate control theory, this technique works to interrupt pain
transmission by "closing the gate". This approach requires training and practice.
Transcutaneous Electrical Nerve Stimulation (TENS): TENS requires the
application of two to four skin electrodes. Pain reduction occurs through a mild
electrical current. The patient can regulate the intensity and frequency of the
 Home care teaching
• Teach the patient and family how to give pain medications.
• Explain to the patient and caregiver about each analgesic's time of intake,
duration, route, expected side effects and importance of PRN dose.
• Write out the instructions clearly on the medicine envelope.
• Encourage the patient to use complementary therapies like distraction, music and
imagining a peaceful scene, as much as possible.
• Explain the importance of drug compliance in pain management and discourage
taking any self-prescribed medications
 Teach the family how to give oral
Morphine
• Teach the patient and family about the rectal route for Morphine administration
in patients who can’t take it orally.
• Advise family on additional methods for pain control - emotional support,
physical method (touch, hot and cold application).
• Give adequate information on managing side effects of analgesics at home (e.g.,
constipation T. Dulcolax 5mg; dry mouth— ice chips, lemon pieces).
• Non-pharmacological interventions: A range of techniques exists to complement
pharmacological approaches. Not all approaches will be appropriate for every
patient. Positioning, reassurance, good communication, psychological support,
joint mobility (passive & active), spiritual counselling, diversion therapy, art or
music therapy, etc., are also useful.
 DYSPNEA
• Dyspnea occurs in almost half of the patients referred for palliative care. It can be
very frightening. It restricts activities. There is a loss of independence, frustration,
anger and depression. Breathlessness at rest can cause anxiety and panic attacks.
Patients often fear suffocating to death. Explanation and support are important.
 Causes
Related to Cancer
• Cancer of the lungs, trachea or throat
• Cancer has spread to other parts of the body
• Distension of the stomach due to either cancer or fluid
Unrelated to cancer
• Asthma
• Infections:Tuberculosis, Pneumonia etc.
• Cardiac- related issues
• Tobacco induced - lung diseases
• Anemia related to cancer
 Management
1. Some causes are reversible. e.g., wheezing due to tightening of airways. It can
be made better with medicines given by the doctor. Check if the patient has been
given any drugs or nebulizer earlier
2. Morphine is very helpful in decreasing breathlessness by acting on various
centers in the brain.
3. Oxygen: It may help in a few cases where there is less oxygen in the blood, but
in cases where the disease destroys the lungs, it may not help.
Possible cause Management
• Asthma -Bronchodilators, Corticosteroids, Physiotherapy
• Pulmonary oedema- Diuretics, Morphine
• Pneumonia- Antibiotics, Physiotherapy
• Pneumothorax- Chest drainage, Oxygen
Non-Pharmacological Management
 Positioning – Make the patient to sit in Fowler’s position; avoid abdominal or chest
 compression and restrictive clothing
 Airflow - encourage cool air flow over the face - open window, electric fan,
ceiling fan, handheld fan
 Distraction - reading, relaxation, company, music, TV or radio
 Energy conservation / Functional pacing
 Encourage pacing and planning of exertion to tolerance.
 Controlled Breathing: Aim to reduce the rate of breathing (breath in, blow out)
 Encourage diaphragmatic (“use lower chest muscles”) and pursed-lip breathing.
 Encourage relaxation of shoulders (e.g., take the weight off the shoulders by
resting arms on support) and upper chest muscles on breathing
 Loose, comfortable clothes
 Wiping the face with a wet towel
 Massage of the shoulders may further assist relaxation and encourage
diaphragmatic breathing.
 Assess psychological factors: Listen to, understand, and address the patient's
fears.
 Relaxation techniques used regularly can reduce long-term levels of anxiety
and can be taught.
 Dyspnea is frightening to patients, families and staff. Reassurance and
explanation are vital parts of the treatment, whatever the cause.
 Modifying lifestyle, breathing retraining and relaxation may be beneficial if
instituted early.
 Consider referral to a physiotherapist or occupational therapist.
 A portable/table fan directed onto the face often eases dyspnea.
 Good oral care is important if there is persistent mouth breathing.
 Humidified oxygen may help acute dyspnea but should be used alongside
other measures, and its use should be reviewed regularly.
 Respiratory physicians only should instigate long- term oxygen therapy for
chronic respiratory illness.
 NAUSEA AND VOMITING
•Nausea and vomiting can cause patients and their relatives great distress. Of the
two, nausea causes the most prolonged misery. Many patients can tolerate one or
two episodes of vomiting a day, while persistent nausea can be profoundly
debilitating.
•Nausea is an unpleasant wave-like sensation in the back of the throat epigastrium
or throughout the abdomen that may or may not lead to vomiting.
•Vomiting occurs when the contents of the stomach are forcibly and involuntarily
expelled. It is generally preceded by nausea. In illnesses like cancer, problems in
the food pipe and stomach/ bowel often result in severe vomiting and nausea.
Chemotherapy medicines used in cancer also cause vomiting. Vomiting is found
in bedridden patients due to certain other reasons too.
•Retching is the movement of the diaphragm and abdominal muscles in a
•spasmodic, rhythmic manner. Usually, nausea is present, and the action results in
•vomiting. Retching is an attempt to vomit without expelling the contents.
 Assessment
• Onset:-When did the vomiting start? Is it related to food intake? What is
the time interval between food intake and vomiting?
• Amount:-Number of episodes of vomitingWhat is the quantity of the
vomitus? (Overall/ Each episode)
• Colour:-What is the colour of the vomitus?
• Is there any bloodstain in the vomitus?
• Smell
• What is the colour of the vomitus?
• Is there any bloodstain in the vomitus?
• Frequency
• What is the colour of the vomitus?
• Is there any bloodstain in the vomitus?
 Management of Nausea and Vomiting

[Link] to provide care to the patient in a well-ventilated room. Put on the fan if
needed.
[Link] smells that cause nausea, e.g., the smell of cooking, phenol, Dettol, etc.
[Link] a bowl for vomiting close by.
[Link] small portions of food at frequent intervals instead of big meals at one
time.
[Link] liquid in small quantities (1/4 to ½ cup) at intervals of half an hour.
[Link] rice water (water drained out after cooking) or ORT (oral rehydration
[Link]) liquid or tender coconut water can be given.
[Link] to make the patient sit up while eating and let him not lie down immediately
after food.
[Link] the patient the food that they prefer.
[Link] sure that the patient takes plenty of fluids.
[Link] sure that the medication prescribed for vomiting is taken in the proper
dose at the appropriate time.
[Link] the patient is feeling better, begin eating clear soups, mild foods, and
liquids until all symptoms are gone for 12 to 48 hours.
Contd.,
[Link]'t force the patient to eat too much at once. Stretching the stomach
may worsen nausea and cause vomiting
[Link] milk, alcohol, caffeine, carbonated beverages, and most fruit juices.
[Link] may increase feelings of nausea.
Odour: avoid strong smells (e.g. food, infected/necrotic tumours, etc.), use
[Link].
[Link] interventions:
 small amounts of food more frequently
 cold rather than hot food
 avoid spicy, rich, fatty and very sweet food
 salty food tends to be tolerated better, e.g. dry biscuits
 small frequent drinks or sips of fluid
 crushed ice cubes / frozen drinks such as Coke and fruit juice
Ginger is a useful antiemetic, in ginger tea or crystalline form
[Link] oral hygiene (especially after vomits)
[Link]/distraction techniques
[Link]: sitting upright, head of the bed to relieve pressure on the
abdomen
Signs of Dehydration
 Increased thirst
 Dry mouth
 Swollen tongue
 Sunken eyes
 Too little urine
 Dark colour urine
 Confusion
 Skin that withdraws too slowly after being punched
 Weakness
 Dizziness
 Palpitations (feeling that the heart is jumping or pounding)
 Sluggishness
 Fainting
 Home care education
 Encourage small and frequent feeds.
 Encourage the patient to choose the menu.
 Explain to the patient and family about the signs and symptoms of
dehydration and hyponatremia.
 Avoid taking high protein diet when the patient has nausea and vomiting.
 Make sure the patient is taking adequate salt –Normal salt intake 1.0-1.2
gm/day.
 Avoid sitting near the kitchen while cooking. This smell may aggravate nausea.
 Environmental modification – eliminates strong smells and sights.
 Maintain good oral hygiene, especially after episodes of vomiting.
 Use complementary therapy to manage nausea and vomiting, e.g. Distraction.
 Rule out the cause- if it is constipation, consider laxatives or enemas as
 necessary.
Educate the patient and family about taking the medication at the
correct time. (e.g.,[Link] on an empty stomach; T. Metoclopramide
 [Perinorm] 10mg half an hour before food).
 CONSTIPATION

•Constipation occurs when bowel movements become difficult or less

•frequent. Constipation is a common problem in palliative care, affecting up to
90% of patients receiving palliative care. It can be caused by various factors,
including decreased physical activity, decreased intake of fluids, dietary fiber,
medications, and other underlying medical conditions.
•Key Principles
o “Prevention is better than cure”.
o ALWAYS prescribe a laxative when commencing an opioid analgesic.
o Careful assessment of bowel patterns is crucial, e.g., the report of a bowel
movement does not exclude constipation.
o In palliative care patients, constipation treatment differs from that in healthy
active
People.
o Remember, ‘diarrhea’ (spurious diarrhea) can overflow due to faecal paction (a
detailed history can be helpful).
 Causes of Constipation
• General
• Lack of exercise
• Lack of physical activity
• Confusion, sedation
• Sense of guilt as the patient must depend on help for his basic needs.
• Lack of privacy
• Fatigue
• Stress
• Disease-related
•Pain
•Certain health problems like Parkinson's disease, hypothyroidism
•Fatigue
•Intestinal obstruction (Problems in the GI tract that compress or narrow
your colon and rectum can cause constipation.)
•Spinal cord compression
•Dehydration
• Nutritional
• Changes in the type of food.
• Decreased intakeof food and water
• Lack of adequate fibre in food
• Low residue diet
Contd.,
• Drug-induced
• Opioids (Morphine, Tramadol, Codeineetc.)
• Antidiarrheal
• Anti-depressants
Contd.,
• Drug-induced
• Opioids (Morphine, Tramadol, Codeineetc.)
• Antidiarrheal
• Anti-depressants
• Assess for the following
• How often does the patient have a bowelmovement?
• How long has the patient had
• symptoms?
• What does the stools look like and Whetherthe patient has blood in the stool?
• Eating habits
• Level of physical activity
• Type of medicines taken
 Assessment
Bowel pattern
• How regular are your bowel patterns? (Before the onset of illness and now)
Dietary pattern
• Amount of water consumed per day Inclusion of food rich in fibers
Consistency
• Hard stools or soft stools
Duration
• How long have you been having difficulty in bowel movements?When was the last time you passed stool to
your satisfaction?
Associated symptoms
• Vomiting, abdominal pain,
• Abdominal distention/abdominal fullness, Hiccups,Loose stools, visible peristalsis Increased bowel sounds
Drugs
• What medications are you currently on? How frequently are you taking laxatives?
Perineal problems
• Perianal ulcers/fissures, tumours,Haemorrhoids
 • General examination: evidence of dehydration
• Abdominal examination: for prominent faucal masses/other masses
• Auscultate for bowel sounds
• Inspection of the anal area: look for haemorrhoids and anal fissure
• Rectal examination: soft or hard faeces, empty rectum
• If a stoma is present, then gently examine the stoma
•Management
1. Correct any correctable causes.
2. With multiple ongoing risk factors, as they are in most cancer patients, suggest
laxatives regularly versus SOS.
3. Titrate the dose of laxatives according to the response (stool frequency and consistency).
4. Stimulant laxatives are the first choice of laxatives for prevention and treatment.
5. Patients with irritable bowel syndrome may experience painful cramps with stimulant laxatives
and often prefer osmotic laxatives such as lactulose or polyethylene glycol (PEG). However,
lactulose can taste unpleasant and also cause bloating.
6. For patients with opioid-induced constipation, Methyl naltrexone may be helpful after a trial of
7. first-line recommended stimulant laxatives and osmotic laxatives.
8. The rectal interventions are both undignified and unpleasant; however, their short onset of
action can be extremely satisfying. Rectal interventions should be avoided when there is
potential for severe infection (neutropenia), bleeding (thrombocytopenia), or rectal/analdisease.
8. If rectal measures are required (when bowels have not moved for more than three days).
Generally, a stimulant suppository is tried first, then an enema as the next option.
Prevention of constipation
•Simple measures should be incorporated as part of the routine palliative care plan for all
•patients.
• Eating regular meals and making use of gastro colic reflex.
• Check the patients’ perception of their bowel functions.

• Establish what is normal; Be mindful of bowel routine and comfort. Assess the patient's level of discomfort
relating to constipation and its management.
• The aim of treatment is comfortable defecation and not increased stool frequency.
• Prophylaxis is better than treatment. Therapy should be regular and not intermittent, similar to the treatment of
chronic pain. Always add a stimulant laxative with an opioid prescription.
• Mobility: Activity is the key stimulus to colonic peristalsis and defecation. Mobility should be encouraged as
much as physical limitations permit.
• Regular toileting: keep a record of stool frequency.
• Maintain adequate oral fluid and fibre intake. Fibres must be avoided in severe constipation as they can
precipitate colic pain.
• Provide privacy for going to the toilet, and maintain the same even if a bedpan is used.
• If the patient develops loose stool once or twice a day after starting the laxative, continue laxative at a
lower dose than prescribed. If the patient passes a large volume of watery stool more than 4 times a day (always
rule out spurious diarrhea), stop the laxative till stool normalizes, and give ORS in the interim period.
• Even after regular laxative use, 40 to 60% of terminally ill patients need additional rectal evacuation
measures on a continuing basis.
•Role of Nurses in Caring for a Patient with Constipation
 Assess
Include the usual pattern
quantity, of elimination;
frequency, compare
colour and qualityitofwith the present pattern.
stool.
 Ensure privacy for the patient and provide bedside commode or bedpan, if
required.
 Ensure the patient is taking medicines as per the prescription.
 Daily exercise may help to prevent and relieve constipation. Even bedridden
patients shouldbe given some light exercises according to their ability.
 Evaluate usual dietary habits, eating habits and liquid intake.
 Assess activity level.
 Evaluate current medication usage that may contribute to constipation.
 Maintenance of an adequate bowel protocol usually requires a prophylactic stool
 softener and stimulant.
 Encourage patients to drink plenty of fluids as tolerated while increasing their
activity as appropriate.
 High fibre diet (e.g., raw fruits, fresh vegetables, whole grains) to be taken with
adequate fluids.
 Consider enema and suppositories, if the patient can no longer tolerate oral
medications.
 Digitally remove impacted stool if present, before giving suppositories and
enema
Contd.,

• Overflow Diarrhea or Spurious Diarrhea

•Overflow diarrhea, also known as fecal impaction diarrhea, is a type
of diarrhea that occurs when a hard mass of stool becomes impacted in
the rectum and colon, preventing the normal passage of stool. As a
result,
[Link] stool leaks around the impacted mass and causes
Overflow diarrhea can be caused by a various factors, including
chronic constipation, dehydration, poor bowel habits, and certain
medications. It is more commonly seen in elderly
Contd.,
• patients, those with neurological disorders, and those who are bedridden or
have limited mobility.
• Treatment for overflow diarrhea involves removing the impacted
• stool, which can be done using laxatives, enemas, or manual
• evacuation. Once the impaction is removed, a bowel management
• plan should be established to prevent further constipation and the
• development ofoverflow diarrhea. This may include dietary changes,
• the use of stool softeners or laxatives, and establishing a regular
• toileting routine.
• Instructions for home care patients:
[Link] about laxative protocol necessary for the patient.
[Link] to the patient that even though the patient is on a liquid
diet, they are expected topass stools (at least a small volume).
[Link] medical help when the patient has more than 2 to 3 days of constipation
[Link] about spurious diarrhea.
 Diarrhoea
•Diarrhea is a common condition characterized by frequent (more
than three times a day) loose,watery bowel movements.
Causes
•Unusual dietary habits
•Imbalance in laxative therapy
•Drugs: Antibiotics, Chemotherapy etc.
•Partial obstruction/ Fecal impaction
•Radiotherapy
•Rectal tumour/ RVF
•Faecal incontinence, loss of sphincter control
 Symptoms
•Unusual dietary habits
•Imbalance in laxative therapy
•Drugs: Antibiotics, Chemotherapy etc.
•Partial obstruction/ Fecal impaction
•Radiotherapy
•Rectal tumour/ RVF
•Faecal incontinence, loss of sphincter control
Contd.,
Precipitating factor
• Smell, food and other activities
Associated symptom
• Headache, abdominal pain, fever, heartburn, abdominal distention, hiccups,
• constipation, loose stools, signs of dehydration
Sensorium
• Conscious/semi-conscious/unconscious oriented/disoriented/calm/agitated/restless
Vestibular disturbances
• Do you feel dizzy?
Drugs
• What medications are you currently on?Recent chemotherapy or radiotherapy
If on NG tube
• Amount, type and frequency of feeding
Examination
• a) Per-Rectal digital examination if constipated
 Assessment
Bowel pattern
• How regular are your bowel pattern?
• Any recent change in food consumed?
Consistency
• Watery stool or mucoid stools
Duration
• When did the diarrhea start?
• How long have you been having diarrhea?
Frequency
• Number of episodes per day
Associated symptom
• Vomiting
• Abdominal pain or cramps Abdominal distention, Fever
• Signs of dehydration
Drugs
• What medications are you currently on?
• How frequently are you taking laxatives?
General Examination
• Per-Rectal digital examination
• Perianal skin condition
Role of nurses in caring for patients with Diarrhea (in palliative care setting)

• Assess the patient's normal bowel elimination pattern.

• Determine the cause of incontinence.
• Perform per rectal examination to rule out faecal impaction.
• Provide privacy for the patient.
• Ensure close proximity for the toilets/bedpan/commode.
• Ensure the patient has supportive clothing or pads.
• Assess the use of diapers and underpads.
• Assess perineal skin integrity.
• Correct any obvious factors related to the assessment.
• Notify the physician in a suspected case of bacterial infection.
• Educate the patient and family about cleaning the perineum carefully and gently after defecation.
• Instruct patient and family on any untoward signs and symptoms, including dizziness, excessive thirst, fever, etc.
• Provide support to the patient and family.
• Advice to eat small frequent bland meals. Low residue diet –potassium-rich.
• Avoid intake of hyperosmotic supplements.
• Increase fluids in the diet by at least 3 litres/day, which includes electrolyte drinks.
• After each evacuation, wash the perineal area with soap and water and dry them thoroughly.
• Treat any perineal irritation with moisture barrier ointment.
• Dispose pads, diapers, or collection devices as soon as possible.
• Administer drugs as per the prescription: Loperamide, Opioids, Codeine.
• Gradually reintroduce proteins and then fats to the diet as diarrhea resolves.
Instructions for home care patients

[Link] cooking and storing food, the following rules can prevent diarrhea:
 Wash hands before and after taking food
 Always keep food that could spoil in the fridge
 Use only boiled and cooled water.
 Ensure that meat is cooked thoroughly
[Link] eat freshly prepared food (meat, fish, and shellfish).
[Link] to the patient the signs and symptoms of dehydration.
[Link] ORS preparation
[Link]
the burden the carer’s burden and educate that sharing the work will reduce
[Link] the importance of maintaining skin integrity
 ASSESSMENT OF VOMITING
•Consider the route of administration of medication as
• Persistent vomiting may reduce gastric emptying, resulting in decreased drug
absorption.
• The parenteral route may reduce tablet burden, which may be a contributing
factor to Nausea and Vomiting.
• For persistent nausea/vomiting, it is preferable to give subcutaneous infusion
rather than bolus injections which are more apt for a single episode.
• Anti-emetics in suppository or tablet form can also be administered rectally.
Onset When did the vomiting start? Is it related to food intake? What is the time interval between food intake and
vomiting?
Number of episodes of vomiting
What is the quantity of the vomitus? (Overall/ Each episode
Amount

Color What is the colour of the vomitus?

Is there any bloodstain in the vomitus
Smell What is the colour of the vomitus?
Is there any bloodstain in the vomitus?

Frequency What is the colour of the vomitus?

Is there any bloodstain in the vomitus?
?
Precipit What is the colour of the vomitus?
ating Is there any bloodstain in the vomitus?
factor ?
Asso Smell, food and other activities
ciate
d
symp
tom
Sensorium Headache, abdominal pain, fever, heartburn, abdominal distention, hiccups,
constipation, loose stools, signs of dehydration
Vestibu Conscious/semi-conscious/unconscious oriented/disoriented/calm/agitated/restless
lar
 • NUTRITION AND HYDRATION
•Maintaining and correcting nutrition is a significant problem in terminally ill patients, particularly when suffering from advanced malignant disease. Previous surgery, radiotherapy and
chemotherapy worsen the problems. Hence intake of a balanced diet is necessary for mental and physical health. The patient and family must be educated about the importance of nutrition.

•General instructions
 Diet must be planned according to the needs of the patient.
 Procedures to be done at least one hour before the meals.
 Serve the food in a good environment.
 In a bed-ridden patient, assemble everything near the patient and assist if needed.
  Give easily digestible food.
 Give time to the patient to eat the food.
 Talking to the patient while he/she is eating will make the patient feel good.
 Before and after food, give water for hand washing and oral care.
 Ensure adequate intake of fluids and dietary fibre.
 Eat as much as the patient wants and as frequently as he/she wants.
 Give nutritious food and dietary supplements as needed.
 Change food consistency as needed.
 Give nasogastric feeding when the patient is unable to accept oral feeding.
 Prevention and management of oral thrush, nausea, and constipation.
•Causes of deficient Nutrients
•Anorexia
•Nausea and vomiting
•Obstruction in the alimentary tract and poor absorption
•Excessive loss of nutrients
•Cancer cachexia
•Adverse effects of the treatment
•Low socioeconomic status
Contd.,
•In palliative patients:
• Assess the degree of nutritional deficiency.

• Decide the type, quality, route and administration of nutrients.

• Assess effects and side effects for further continuation.

• Consider the physical, psychological, social cultural and financial aspects of the patients and family.

•Routes of administration of Nutrients

• Oral route

• Parenteral route or Central / Peripheral vein

• Oral route is the best, simplest, cheapest and most acceptable method.

•Psychological factors like anxiety, depression and attitude of relatives are also contributing factorsthat affect the appetite of the patients which can be improved by
• Attractive presentation of food
• Pleasant environment
• Correct temperature and aroma of food
• Small frequent feeds
• Taste tolerance
• Effective communication
• Psychological support for both patient and family

•Points to be kept in mind when patient is on naso-gastric feeding:

 Give the patient a Fowlers position or raise the chest with extra pillows.
 Prevent air entry inside the tube by pinching or folding the tube, opening the cap, and fixing thesyringe (20ml or 50ml).
 Aspirate the stomach contents and see whether the tube is in position.
 If the aspiration fluid is more than 50ml, skip the feed.
 Before and after the feed, give about 15- 20 ml of plain water
 Give a total of 200 ml of prepared feed. (Total feed plus water not to exceed
250ml, accordingto the condition of the patient)
 Give the feed slowly without air entry.
 Ensure oral care every 4 hourly.
 Keep the patient in the same position for half an hour.
 Put the patient in side-lying position (to prevent aspiration)

• FATIGUE
•Fatigue is a common symptom in palliative care patients and can significantly
affect their quality of life. There are various reasons why fatigue can occur in
palliative care patients, including the underlying disease, medication side effects
and emotional distress. Therefore, managing fatiguerequires a multidisciplinary
approach that includes medical, psychological, and social interventions. It is the
self-recognized state in which an individual experiences an overwhelming
sustained sense of exhaustion and decreased capacity for physical and mental work
that is not relieved by rest. Fatigue is associated with a various physical and
psychological conditions and not the same as tiredness which is temporary.
•Assessment
 Evaluate the patient’s description of fatigue: severity, changes in severity over time, aggravating or alleviating factors.
 Using an appropriate quantitative scoring scale, 1 to 10, for example, can aid the patient informulating the amount of fatigue experienced.
•Causes of fatigue
 Previous physical illness
 Pain
 Psychological factors
 Side effects of medication
 Anaemia
 Disease progression
 Sleep disorders
 Imbalanced nutrition
 Extended responsibilities and demands at home or work
•Assessment
 Identifying the related factors to fatigue can benefit in recognizing potential causes andbuilding a collaborative plan of care.
 Assess the patient’s ability to perform ADLs.
 Assess the patient’s nutritional ingestion for adequate energy sources and metabolic demands.
 Evaluate the patient’s outlook for fatigue relief, eagerness to participate in strategies toreduce fatigue, and level of family and social support.
 Review results of laboratory or diagnostic test:
 Blood glucose
 Hemoglobin/hematocrit
 BUN
 Oxygen saturation, resting and activity
 Changes in these physiological measures may be associated with other measurement data torecognize possible sources of the patient’s fatigue.
 Observe physiological reaction to activities, such as any alterations
in BP, respiratory rate,or heart rate.
 Assess the patient’s ability for exercise and physical movement.
 Assess the patient’s sleep patterns for quality, quantity, time taken
to fall asleep and feeling upon waking up.
 Observe any alteration in thought processes or behavior after
awakening.
 Assess the patient’s routine medications and self - medications.
 Assess the patient’s emotional reaction to fatigue.
•Management of Fatigue
•Managing fatigue requires a multidisciplinary approach that includes medical, psychological,
and social disease,adjusting
underlying interventions. Medical interventions
medications, and may symptoms
managing include the
that management
contribute to of the
fatigue,
such
massageas pain,
or nausea, andmay
acupuncture, breathlessness.
alsobe used. In some cases,interventions,
Psychological complementarysuchtherapies,
as such or
counselling as
cognitive-
their copingbehavioral therapy,
strategies. Social may help patientsinvolve
interventionsmay to manage emotional
providing distress
practical and improve
support, such as
home carecaregivers.
and their or transportation services, to reduce the physical and emotional burden on patients
•Care of the patient with fatigue
• Restrict environmental stimuli, especially during planned times for rest and sleep.
•
• Encourage
Aid
the patient to maintain a 24-hour fatigue or activity log for at least 1 week.
theimportance ofwith
the patient developing
frequent a schedule for daily activity and rest. Emphasize
rest periods.
• Teach energy conservation methods. Collaborate with an occupational therapist as
needed.
• Assist the patient with setting priorities for preferred activities and role responsibilities.
• Promote sufficient nutritional intake.
• Provide comforts such as judicious touch or massage and cool showers.
• Encourage verbalization of feelings about the impact of fatigue.
•
• Offer
Identify
diversional activities that are soothing.
energy conservation methods such as sitting and dividing ADLs into
convenientsegments.
• Set practical activity goals with the patient.
• Stay away from topics that annoy or disturb the patient.
• Aid the patient in developing habits to promote effective rest/sleep patterns.
 • POWERLESSNESS
•Powerlessness is a common experience for many patients receiving palliative
care, as they may feel they have little control over their illness and the care
they receive. This can be particularlychallenging for patients who are used to
being independent and making their own decisions.
Powerlessness means that the person does not have the strength or resources to
change a situation. People with chronic conditions often have a long‐term
experience of powerlessness because they feel unable to change outcomes.
Managing real and perceived powerlessness is significant. Lack of control and
the incapacity to act and change may dominate everyday life for persons with
chronic illnesses. Accepting and acknowledging one’s limitations due to
chronic illness may result in a sense of helplessness.
 • Despite the limiting effects of chronic illness and feelings of powerlessness, individuals
continue to exert power and control in areas of their lives through adaptation and accommodation
to their evolving abilities. When power resources are significantly altered and affected, an
individual
•with chronic illness may experience feelings of powerlessness. To deal with this powerlessness,
persons with chronic illness should direct their energy toward their intact power resources.
•The patient may experience Powerlessness as:
 A disruption of identity
 Loss of familiarity with bodily responses
 Loss of familiarity with emotional responses
 Loss of familiarity with social standing
 Loss of familiarity with one’s environment
•Assessment
 Assess for feelings of apathy, hopelessness, and depression. These are the element
ofpowerlessness.
 Determine the patient’s power needs or need for control.
 Evaluate the patient’s decision-making competence.

 Know situations/interactions that may add to the patient’s sense of powerlessness.
Appraise the impact of powerlessness
appearance,oral intake, hygiene, sleep on the patient’s physical condition (e.g.,
habits).
 Assess the role of illness plays in the patient’s sense of powerlessness.
 Note if the patient needs information about illness, treatment plan, and procedures.
•Care of patients experiencing powerlessness
 Therapeutic communication - encourage
and concernsabout making decisions. verbalization of feelings, thoughts,

 Encourage the patient to identify strengths.
Discuss with the patient concerning their care (e.g., treatment options, the
convenience ofvisits, or time of ADLs).
 Encourage an increased responsibility for self-care.

 Help the patient re-examine negative perceptions of the situation.
Eliminate the unpredictability of events by allowing adequate preparation for
tests orprocedures.
 Give the patient control over their environment.
 Aid the patient in recognizing the importance of culture, religion, race, gender,
and age ontheir sense of powerlessness.
 Support in planning and creating a timetable to manage increased responsibility
 in thefuture.
 Use of realistic short-term goals for resuming aspects of self-care and foster
 confidence inone’s abilities.
 Avoid using coercive power when approaching the patient.
 Render positive feedback for making decisions and engaging in self-care.
 • ANXIETY
•Anxiety is a common issue for patients receiving palliative care. It
can severely impair their quality of life and limit their mobility, social
interaction, enjoyment, and sense of well-being. Anxiety can be
caused by a various factors, including the patient's physical
symptoms, the emotional impact of the illness, and uncertainty about
the future. Anxiety disorders often co-exist
•with depression in palliative care patients.

•To help manage anxiety in palliative care, healthcare providers may use a combination
of pharmacological and non-pharmacological interventions. Medications such as
benzodiazepines or antidepressants may be used to reduce anxiety symptoms, while
non-pharmacological interventionssuch as relaxation techniques, mindfulness meditation,
and counselling may also be helpful. It's important to note that anxiety is a normal
response to the stress and uncertainty of serious illness. Itis important for healthcare
providers to provide emotional support to these patients. They can alsowork with the
patient and their family to develop a care plan that addresses the patient's anxiety
andsupports their overall well-being.
•Anxiety
 Assessassessment
the signs and
tension,autonomic symptoms of
hyperactivity, andanxiety likescanning.
vigilance/ excessive worrying, increased motor
 Assessment of the nature of anxiety, acute or chronic and whether part of another
psychiatricsyndrome such as a depressive disorder.
 Assessment for or
Stimulant drugs anyexcessive
reversible factors
alcohol suchoraswithdrawal
intake pain or inappropriate medications.
may exacerbate anxiety.
 Understand the unexplored worries. It is necessary to provide time and opportunity for
patients to express their worries and concerns and for these concerns to be
•Management of Anxiety
•A non-pharmacological approach is recommended before initiating pharmacological therapy in managing palliative care patients.

•Lifestyle modifications:

A) Exercise:
•Moderate exercise that is appropriate for an individual’s functional ability is helpful. Walking outside or in the park at a pace that an individual can tolerate will be sufficient. Bedridden and
wheelchair-bound individuals can do simple stretching, flexion and extension exercises. Patients who are too frail can try walking within the home with support and supervision.

B) Diet:
 The deficiency of vitamins B1, B6, B12, and folic acid can be mistaken for anxiety disorder.
 Similarly, alterations in the serum electrolytes can cause anxiety symptoms.
 Discussing the importance of balanced diet may be the only intervention required in somepatients with anxiety.

C) Sleep:
 Sleep and anxiety are strongly linked. Anxiety can cause insomnia.
 Sleep hygiene education can promote good sleep, which includes avoiding frequent daytimenaps, late evening exercises, late heavy dinners, reducing intake of stimulants, reducing
ambient noise and controlling other environmental factors that disturb sleep.
 Some drugs may also disturb sleep pattern (diuretics, steroids etc.,)
 Guided imagery is useful in preventing anxious thoughts that prevent sleep onset
 D) Relaxation techniques:
 Jacobson muscle relaxation technique or progressive muscle relaxation technique can be taught to patients with anxiety. This technique involves sequentially tightening (5
seconds) and relaxing (10 seconds) the specific muscle groups.
 This technique can be combined with mental imagery and breathing exercises.
E) Mindfulness:
•Mindfulness involves focusing on the present. The idea is to notice the details like smell, texture, colour, patterns, taste and emotions. There are several ways of practicing mindfulness: walking
outside, looking through a window, doodling, brewing tea, staying away from the phone, journaling,etc.

F) Social activities and networking:

•Social interactions and networking maintain connectedness. It is not only an essential social stimulusbut also improves synaptic connections. Purposeful social connections directed towards
common goals offer engagement, focus and direction- e.g., Prayer gatherings, book clubs, social tasks, etc.
•Pharmacological management
•Consider the following principles in the pharmacological management of anxiety disorders.
 SSRIs (Selective Serotonin Reuptake Inhibitors) are the first line of choice.
 When SSRIs fail, then move to other groups like Serotonin-Norepinephrine Reuptake Inhibitor (SNRIs), Tricyclic antidepressants (TCAs)
 Always monitor for hyponatremia and bleeding manifestations when SSRIs and SNRIs are used.
 Benzodiazepines have neuro-cognitive effects, can cause confusion, and dissociative phenomena, and increase the risk of falls. Avoid using benzodiazepines as much as
[Link] used, limit use to 2 to 4 weeks.
•Nursing Interventions for Anxiety
•Nursing interventions for Anxiety can apply to any individual with anxiety, regardless of etiologic and contributing factors.
 Recognize awareness of the patient’s anxiety.
 Acknowledgement of the patient’s feelings validates and communicates acceptance of thosefeelings.
 Use presence, touch (with permission), verbalization, and demeanor to remind patients that they are not alone and to encourage expression or clarification of needs, concerns,
unknowns, and questions.
 Familiarize the patient with the environment and new experiences or people as needed.
 Interact with patients peacefully.
 Accept the patient’s defenses; do not dare, argue, or debate.
 Communicate in simple language and brief statements.
 Reinforce the patient’s reaction to or expression of pain, discomfort, or threats to well- being(e.g., talking, crying, walking, and other physical or nonverbal expressions).
 Lessen sensory stimuli by keeping a quiet and peaceful environment; keep “threatening” equipment out of sight.
 Allow the patient to talk about anxious feelings and examine anxiety-provoking situations if they are identifiable.
 If the situational response is rational, use empathy to encourage the patient to interpret the anxiety symptoms as normal.
 Recommend patients to keep a log of episodes of anxiety. Instruct the patient to describe
• Recognition
What is experienced and the events leading up to and surrounding the event.
and exploration of factors leading to or reducing anxious
feelings are important
may be unaware of the steps in developing
relationship alternative
between responses.
emotional concernsThe and patient
anxiety.
 Encourage the patient to consider positive self-talk like “Anxiety won’t kill
me,” “I can
stretch,” “I do this
don’t onetostep
have be at a time,” “Right
perfect.” now I need
Cognitive to breathe
therapies focus and
on
changing
negative behaviors and
self-statements feelings
with by
positive changing
self-statementsthoughts.
aids in Replacing
reducing
anxiety.
 Consider the patient’s use of coping strategies that the patient has found
effective in the past.
 Avoid unnecessary reassurance; this may increase undue worry.
 Reassurance is not helpful for the anxious individual.
 Assist the patient in developing new anxiety-reducing skills (e.g.,
relaxation,
statements).deep breathing,positive visualization, and reassuring self-
 Intervene when possible to eliminate sources of anxiety.
 SOCIAL ISOLATION

• Lack of social contacts and interaction with very few people can lead
to social
that is isolation.
their Peoplesense
self-image, usually
of face somerelationships,
control, loss at the end
or ofindependence.
life, whether
This can
including mean that
hobbies, people
interests,are isolated from
friendsrelevant
and what the things they
ultimatelyhas love
makes the most,
them their
feel
like themselves.
living This
accommodation is particularly
to allow for care. if someone
Loneliness is a to
sad change
feeling of
isolation
or despair. from others, is
Loneliness usually
bad accompanied
for physical andbypsychological
mental fatigue, bitterness,
health, while
membership insocial groups acts as an umbrella in its appearance.
•Causes of social isolation:
• Loss of spouse
• Migration of children
• Empty nest Syndrome
• Financial insecurity
• Disability
• Social status
• Underlying psychiatric illnesses
• Depression
•Approach to Social Isolation
•To address social isolation in palliative care, providers can take several
aproaches. One approach is to provide social support through hospice or
palliative care services. These services mayinclude support groups, counseling,
and spiritual care, all of which can help patients feel less isolatedand more
connected to others.
•Another approach is to involve family and friends in the patient's care. This
can help to maintain important relationships and provide emotional support to
the patient. Palliative care providers can work with patients and their families
to identify ways to involve loved ones in the care process, such as attending
medical
together. appointments, helping with daily activities, or simply spending time
•Technology can also be valuable in addressing social isolation in palliative
care. Telemedicine and other communication tools can help patients stay
•connected with their care providers and loved ones, even if they cannot be
together physically.
 • SPIRITUAL DISTRESS
• Spirituality is “a dynamic and intrinsic aspect of humanity through which
persons seek
• Ultimate meaning, purpose and transcendence and experience relationship to
self, family,
•community, society and nature. Spirituality is expressed through beliefs,
values, traditions and practices.” Spirituality is a very fluid concept. People tend
to define it in very different ways. Some associate it with their concept of God,
some do not.
•Spiritual distress is an impaired ability to experience and integrate meaning
and purpose through connectedness with self, others, art, music, literature,
nature,
the and/or power greater than oneself. When people get sicker and approach
end of their life’s journey, there is often a great deal of spiritual distress and
suffering.
way. Each person needs to come in to terms with their losses in their own
We are there to walk with them on that journey, not to tell them what to think, feel
or [Link], we must not try to take the suffering away by trying to
impose our own spiritual solutionsonto their spiritual struggles.
•Assessment of Spiritual Distress
 Assess history of religious affiliation.
 Assess spiritual beliefs.
 Assess the spiritual meaning of illness and death.
o “Do you wonder regarding the meaning of your illness?”
o “How does the current situation affect your relationship with God, your beliefs, orother sources of strength?”
o “Do your illness and grief interfere with expressing your spiritual beliefs?”

 Assess whether patients need help with unfinished business.

•Approach to spiritual Distress

 Provide understanding and acceptance.
 Support crying by offering caring touch.
 Encourage verbalization of feelings of anger or loneliness.
 When the patient requests, arrange for priests, rituals, music, prayers, scriptures or images.
 If requested, sit with the patient who wishes to pray and arrange for a priest at the time ofdeath as per their request.
 Do not provide intellectual solutions for spiritual problems
•To address spiritual distress in palliative care, providers can take
several approaches.
counselling, prayer, Oneother
and approachis
forms to
of provide
spiritual spiritual
support. care, including
Palliative care
providers
preferences canand
work with patients
develop a care to identify
plan that their spiritual
addresses them. needs and
Another
approach
These involvescan
individuals chaplains
provideoradditional
other spiritualleaders
spiritual in the
support andcare team.
guidance
and help patients connect with their faith communities and religious
traditions.
•
•Mobility isIMPAIRED PHYSICAL MOBILITY
It encompasses the abilitystrength,
muscle to move the
rangeentire
of body freelyand
motion, andendurance
normally.
capacity.
both Mobility
simple along is
gross with associated
motorassociated with
movements physical
and more of movement,
complex including
fine motor
movements,
With mobility,orone coordination those movements.
can move functionally and efficiently with little to
no restrictions difficulty.
 Assess input and output records and nutritional patterns.
 Monitor nutritional needs as they relate to immobility.
 Evaluate the need for assistive devices.
 Assess the presence or degree of exercise-related pain and changes in joint
mobility.
 Assess the safety of the environment.
 Assess the emotional response to the disability or limitation.
 Consider the need for home assistance (e.g., visiting home care team).
 Assess the patient’s or caregiver’s understanding of immobility and its
 implications.
Note for localizedswelling,
progressing thrombophlebitis (e.g., calf pain, Homan’s sign,
redness, a rise in temperature).
 Check for skin integrity for signs of redness and tissue ischemia
(especially
toes). over ears,shoulders, elbows, sacrum, hips, heels, ankles, and
•Nursing
 Assist Interventions for impaired physical mobility
patient for muscle
knee bends; hop on foot; stand exercises as able or when allowed out of bed; execute abdominal
on toes. exercises and
 Present a safe environment: bed rails up, bed in a down position, and essential items closeby.
 Establish measures to prevent skin breakdown and thrombophlebitis from prolonged immobility.
 Clean, dry, and moisturize the skin as necessary.
 Use anti-embolic stockings or sequential compression devices if appropriate.
 Use pressure-relieving devices as indicated (air/water/gel mattress). This is to prevent skin stasis
breakdown, and
the compression
thrombophlebitis devices
inischemia promote
the legs. or
It may an increased
also decrease venous
pressure return
on skin to prevent venous and possible
or tissues that can damage circulation,
potentiating tissue breakdown and decubitus formation risk.
 Turn and position the patient every 2 hours or as needed. Position changes optimize circulation to all tissues and
 relieve
Execute
pressure.
passive or active assistive ROM exercises to all extremities to enhance increased venous return,
prevent
build up stiffness,
quickly and
and maintain
could hindermuscle strength
prosthesis and
usage. stamina. It also avoids contracture deformation, which can
 Promote and facilitate early ambulation when possible. Aid with each initial change:dangling legs, sitting in
the chair, ambulation.
 Show the use of mobility devices, such as trapeze, crutches, or walkers. These devices can compensate for
impaired function and enhance the level of activity. Such aids are to promote safety, enhance mobility,
 avoid
Help
falls, and conserve energy.
with transfer methods by using reasonable assistance of persons or devices when transferring
patients to bed, chair, or stretcher.
 Let the patient accomplish tasks at their own pace. Do not hurry the patient. Encourage
activity as able and safe. independent
 Give positive reinforcement during the activity. Patients may be unwilling to move or initiate new activities
because of fear of falling.
 Consider energy-saving techniques. Rest periods are essential to conserving energy. Provide
rest periods in between activities. the patient with
 Give medications as appropriate. Antispasmodic medications may reduce muscle spasms or spasticity that
interfere with mobility, analgesics may reduce the pain that impedes movement.
 Help the patient in accepting limitations. Let the patient understand and accept theirlimitations and abilities. On
the other hand, assistance must be balanced to prevent the patient from being unnecessarily dependent.
• and other forms
and reducing the of
riskexercise
of falling areinbelieved to be effective in maintaining independentliving status
older adults.
 Help the pathways
patient develop sitting balance and standing balance. This helps out in retraining
 neuronal and motor responses.
Keep
wedges, limbs
or in functionalsplints.
prefabricated alignment withfeet
Maintain oneinora dorsiflexed
more of theposition.
following:
This pillows, sandbags,
avoidsfoot drop and
too much plantar flexion or tightness.
 Encourage coughing and deep-breathing exercises. Use suction as necessary. Make use of an
 incentive
Present
spirometer.
suggestions for nutritional intaketo for adequate energy resources and metabolic
requirements. Correct nutrition is necessary keep a sufficient energy
 Encourage a diet high in fibre and a liquid intake of 2000 to 3000 ml per day unless level.
contraindicated.
decreases the riskLiquids maximize
of skin irritation or hydration
[Link] and avoid hardening of stool. It also
 A sedentary lifestyle contributes to constipation. Set up a bowel program (e.g., adequate fluid, food
 high
Offer
in bulk, physical activity, stool softeners, laxatives) as needed. Note bowelactivity levels.
diversional [Link]
Observe emotional or behavioral reactions to helps
immobility. Forced
immobility may heighten
attention and promotes coping with limitations. and irritability. Diversional activity in refocusing
 Explain to the patient the need to call for help, such as a call bell and special sensitive call light.
 Set goals with the patient or significant other for cooperation in activities or exercise and position
changes.
 Reinforce
point of principles
pain, not of progressive
beyond. “No exercise,
pain, no gain” emphasizing
is not always that joints
true! Painare to bebecause
occurs exercised to the
ofjoint or
muscle injury.
 Teach the patient or family to maintain a home atmosphere hazard-free and safe to prevent injury
related
fatigue to
withfalls and help the patient maintain a desired level of functional independenceand reduce
activity.
 Explain the progressive activity to the patient. This may help to increase self-confidence and
reduce frustration.
•Patient teaching
 Adherence to recommended prevention and treatment strategies can significantly affect whether the patient will regain mobility or develop
immobility-related complications.
 Educate patients and their families regarding the risks of impaired mobility and the importance of maintaining the highest level of physical activity
possible.
 Discuss the importance of turning and repositioning to maintain skin integrity. Explain that passive and active range-of-motion exercises will help the
patient maintain joint flexibility, muscle strength, and muscle mass.
 Discuss fall prevention techniques. For example, teach patients to change positions slowly to avoid orthostatic hypotension.
 Stress the importance of optimal nutrition in healing; the patient and family should understand that meals high in protein and nutrients benefit healing.
Also, inform patients about the importance of adequate fluid intake to help prevent both urinary tract infections and constipation.
 The psychological impact due to impaired mobility and immobility can be devastating. Provide the patient and family with information about support
groups and community resources as appropriate for any identified physiological, psychosocial, spiritual, and financial needs
 •
•Self-care refers to thoseSELF CARE DEFICIT
maintain personal activities
well-being. an
Activitiesindividual
of daily performs
living or independently
ADLs are throughout
defined as the life we
task to promote
regularly and
do
such as feeding ourselves, bathing, dressing, grooming,
some that might have difficulties in performing self-care. work, homemaking and leisure. However, there are
• Self-care deficit is the inability of an individual to perform self-care. The deficit may be the effectof
temporary
gradual limitations,that
deterioration such as those
erodes the one might experience
individual’s ability or while recovering
willingness to from the
perform surgery, or theresult
activities required of
to
care for themselves.
•Assisting in activities of daily living is the skill required in nursing. The nurse coordinates servicesto
maximize
supportive the patient's
of their specialindependence
needs. and ensure that the environment the patient lives in is safe and
•Assessment
 Assess the patient’s strength to accomplish ADLs efficiently and cautiously on a daily basis. The
patient may need help with some self-care measures related to eating, bathing, grooming, dressing,
 toileting, bladder and bowel management, transfer, ambulation, and/orstair climbing.
Determine
impairment).the specific cause of each deficit (e.g., visual problems, weakness, cognitive
 Consider the patient’s need for assistive devices.
 Recognize choice for food, personal care items, and other things.
 Evaluate gag reflex prior to initial oral feeding.
 Verify the need for home health care after discharge.
 Monitor impulsive behavior or actions indicative of altered judgment.
•Transferring/Ambulation
 For moderate assistance, the caregiver places arms beneath both patient’s armpits with the caregiver’s hands on the
patient’s back.
 For patients needing maximal assistance, use a gait belt.
 Raise the bed to a height that allows the patient’s feet to be flat on the floor.

 Grasp
Place a
the gait belt with both arms and pull the patient forward.
kneethe
against the patient’s weak knee (if applicable) and encourage the patient to put weight on the strong
 side during transfer.
Encourage the patient to use their arms to assist, as able, and to place them on the caregiver’s forearms.
 This method maximizes patient support while protecting the care provider from injury.
 Aid with ambulation, direct use ambulation devices such as canes, walkers, and crutches.

 Stand on the patient’s weak side.
If using a cane, place the cane in the patient’s strong hand and ensure proper foot-cane sequence.
 These methods promote patient safety and aid with balance and support.

•Toileting
 Assess
programprevious and present
will be improved patterns
if the for toileting,
patient's natural andintroduce
personala patterns
toiletingare
routine. The efficacyof the bowel or bladder
considered.
 Assess patient’s ability to verbalize necessitate to void and/or capacity to use the urinal and bedpan. If suitable,
 bring the patient to the bathroom regularly or intermittently for voiding.
Provide
and privacy while the patient is toileting. Lack of privacy may reduce the patient’s ability to empty the bowel
bladder.
 Give aTime
bedpan or put can
the patient on the as
toilet every 1 starts
to 1½tohours throughout thetoday andon
three times This
throughout the
night.
incontinence. intervals be prolonged the patient verbalize the need toilet demand. eradicates
 Give suppositories and stool softeners.
  Ensure that the consistency of diet is suitable based on the patient’s ability to chew and
swallow. Thickened semisolid foods such as pudding and hot cereal are most easily
 swallowed
If vision is
and less likely to be aspirated.
affected, guide the patient about the placement of food and
on the plate. After
Cerebro vascular
of the plate. accident (CVA), patients may have unilateral neglect may ignore half
 Provide an appropriate setting for feeding where the patient has supportive assistance.
•Dressing/Grooming

 Provide
Use
privacy during dressing.
appropriate assistive devices for dressing as assessed by the nurse and occupational
therapist.

 Suggest
Give
elastic shoelaces or Velcro closures on shoes.
frequent encouragement and aid while dressing as needed. Assistance can reduce
energy expenditure and frustration.
 Dressing requires energy. Utilise a wheelchair or stationary chair. A chair that provides
more support for the body than sitting on the side of the bed saves energy when dressing.
 Establish regular activities so the patient is rested before any activity.
 Consider the use of clothing one size larger.
 Recommend a front-opening brassiere and half-slips in females.
• Nursing Interventions
 Establish short-term goals with the patient to help them set realistic goals to reduce frustration.
 Guide the patient in accepting the needed amount of dependence.
 Present positive reinforcement for all activities attempted, note partial achievements.
 Render supervision for each activity until the patient exhibits the skill effectively and is secured in
independent care. Regularly re-evaluate to ensure that the patient is keeping the skill level and remains safe
 in the environment.
Implement measures to promote independence but intervene when the patient cannot function.
 Boost maximum independence.
 Apply regular routines and allow adequate time for the patient to complete the task.

•Feeding
 Allow the patients to feed themselves as soon as possible (using the unaffected hand, if appropriate). Assist
with the set up as needed. The dominant hand may also be affected if there is upper extremity involvement.
 Ensure the patient wears dentures, hearing aid and eyeglasses if required.

 Place
Provide
the patient in a comfortable position for feeding.
the patient with proper utensils (e.g., wide-grip utensils, rocking knife, plate guard, drinking straw) to
aid in self-feeding.
 Observe the patient closely for loss of balance or fall. Maintain commode and toilet tissue close to the
bedside for night time utilization. Patients may hurry to the toilet or commode throughout the night due to
 fear
Keep
of soiling themselves and may fall.
the calltransfer
light within reach and or teach the patient to call promptly. This allows staff members ample
time to help to the commode toilet.
 Aid patients in eliminating or changing unnecessary clothing. Clothing that is not easy to getin and out
 may compromise a patient’s capability to be continent.
Consider utilization of commode or on
toilet as earlySeveral
as possible. Patients
their bowel and bladder when sitting commode. patients find itare more successful
unfeasible in emptying
using a bedpan.
 Recognize prior bowel habits and restore normal regimen. Increase bulk in diet, fluid intake,and activity. It
 supports
Educate
the progression of retraining program and helps avoid constipation and impaction.
family and significant othersdisplays
to promote autonomy and but
intervene if the patient becomesefforts
tired,
incapable of carrying
to attain autonomy. out tasks. This caring and concern does nothinder with patient’s
 Inform family members to allow the patient to perform self-care measures as much as possible.
 Note: This may be very hard and discouraging for the significant other or caregiver, depending
 on the extent of the disability and the time needed for the patient to accomplish the activity.
Promote independence butavoid
intervene
 level of assistive care can harmwhen the patient
with activities cannotcausing
without carry out self-care activities. A suitable
disappointment.
Entertain
are taken patient
into input in thein
consideration planning
daily schedule. Patient’s worth of life is improved when wishes or likes
activities.
 Consider or use energy-conservation techniques. This saves energy, decreases fatigue, and improves the
patient’s capability to execute tasks.
 • DELIRIUM
• Delirium is a disturbance in consciousness and cognition that can result in confusion, disorientation, and difficulty with memory, attention, and thinking. Delirium is a
state of mental confusion that develops quickly, usually fluctuates in intensity, and results in reduced awareness of and responsiveness to the environment. It
may manifest as disorientation, incoherence and memory disturbance. Delirium is a common issue for patients receiving palliative care, especiallyin the advanced
stages of their illness.

• Causes
• Infection: Pneumonia, sepsis
• Metabolic encephalopathy: organ failure, paraneoplastic syndromes
• Endocrine: Hyper/hypothyroidism, Cushing syndrome
• Drug withdrawal: Alcohol, narcotics, hallucinogens
• Immunologic: Systemic lupus erythematosus (SLE), vasculitis
• Nutritional deficiencies
• Drugs

•Approach to Delirium
• Monitor and record consciousness level, temperature, pain scores, pressure sores, and neurological and rectal examination findings.
• Administer drugs as per the prescription.
 • Stop any offending treatment.
• Correct metabolic abnormalities.
• Quiet room, dim lights, calendar, clock.
• Family support.
• Treat reversible causes (dehydration, hypercalcemia etc.)
•Nursing Management
 Identify the cause, including the precipitating, aggravating, and palliating factors.
 Provide pharmacological and non-pharmacological management.

 Providing
Communicate
a safe environment and reassuring the patient that we keep them safe.
with the patient and family calmly, with a non-judgmental attitude, and use simple
terms.

 Give
Pay
only one choice or one decision to prevent agitation.
active listening when they express their feelings during delirium and support the patientand
family.
 Get the complete history of the recent changes after the health team visit and investigationor
medication.

 Keep the patient hydrated and maintain the nutritional status.
Maintain and and
encourage the family members to maintain normal urinary and bowel patterns
(constipation urine retention can cause delirium).
 To avoid anxiety and fear, minimize unnecessary stimuli. Encourage the use of assistive devices.
 Maintaining proper position technique encourages active and passive exercise.

 Effectively
Administer
manage the pain because it can exacerbate delirium.
medications,
following safe medicationsuch as antipsychotics,
administration [Link], and analgesics, as prescribed,

 Monitor
Reorient
for adverse reactions, including increased confusion.
theboard
patient
orientation on continuously about
the wall facing the time, place, and person. Keep the clock, calendar,
the patient.
 Call the patient by name and give them a mirror to help him get oriented by
himself.
 Maintain a consistent schedule and stable environment.
 Keep the patient’s belongings in the same location to decrease confusion.
 Provide music, magazines, and games with which he was familiar earlier.
 Encourage the family to talk about the past event step by step.
 Suggest to the family the importance of following sleep hygiene for these
 patients.
Try to care for the patient withthe
thepatient
same room.
team members and avoid
unnecessary equipment inside
 Managing a patient with delirium in the home is extremely stressful for the
family.
necessaryAssessthe
[Link] members' coping abilities and provide the
 An interdisciplinary team approach is needed to manage these patients.
 Palliative sedation is preferred at the end of life in reducing or eliminating
symptoms
during this as a primary
critical goal and supporting the family or other caregivers
period.
 Call the patient by name and give them a mirror to help him get oriented by
himself.
 Maintain a consistent schedule and stable environment.
 Keep the patient’s belongings in the same location to decrease confusion.
 Provide music, magazines, and games with which he was familiar earlier.
 Encourage the family to talk about the past event step by step.
 Suggest to the family the importance of following sleep hygiene for these
 patients.
Try to careinside
for thethepatient with the same team members and avoid unnecessary
equipment patient room.
 Managing a patient with delirium in the home is extremely stressful for the
family.
[Link] family members' coping abilities and provide the necessary

 An interdisciplinary team approach is needed to manage these patients.
Palliative sedation is preferred atsupporting
the end ofthe
lifefamily
in reducing or caregivers
eliminatingduring
symptoms as a primary
this critical period. goal and or other
•Caregiver strain is a common issue in palliative care, as caregivers often experience physical, emotional, and social stress associated with caring for a loved one
who is terminally ill. The excessive stress and demands on caregivers can lead to care giver role strain which is experienced when a caregiver feels
overwhelmed and cannot perform their role to the best of their ability. Caregiver role strain symptoms are very similar to everyday
stress and include

displaying an inability
feeling to relax, and
being
having widespread aches and pains
pessimistic,
(among many other things). Feeling of
stress and anxietyoverwhelmed,
accompany it. FIG.3.10: CARE
GIVER
•Caregiver strain often goes
•unrecognized. In the hustle and bustle of a busy life, it may not be detected until the family caregiver suffers a health crisis
of their own.
•Interventions
•There are steps you can advise a family caregiver to decrease the caregiver strain. Advise them to
 Utilize in-home care services: Respite care to take a personal break, adult day care, counselling and
rehabilitation services on a routine basis to assist with the family member’s care.
 Seek financial help: If finances are an issue, approach an ASHA worker, who may advise you on available
resources to help bridge the gap. She may also refer to Village Health, Sanitation and Nutrition Committee/Jan
Arogya Samiti/ Mahila Arogya Samiti/ Resident Welfare Association who will ensure the availability of benefits
 from various governments and non-governmental programs/ schemes to the eligible patients/ caregivers.
Ask forIt and
needs. is accept help.
challenging to Many
do andfamily
can putcaregivers
both at feelfor
risk obligated
illness to injury.
or provideMake
all thea care
list and
of support
the task theircould
others lovedhelp
one
with and ask other family members to help with those specific chores.
 Set reasonable expectations for self and others. Care rendered may differ from person to person and should not
be criticized. Let the care given be good enough to keep the patient from risk for injury.
 Talk with the physician/nurse and make sure they know about the family caregiver. They may want to take extra
steps to protect the caregiver’s health, such as monitoring the blood pressure at home or prescribing a vitamin
 supplement.
Encourage self-care.
brisk walk five days a This
weekmay
and be
eat the mostdiet
a good difficult onethem
can help for family
to staycaregivers
healthy. to accept, but making time to take a
 Education and support: Providing caregivers with education about the patient's illness, trajectory, and symptom
management can help them better understand and cope with the situation. Caregivers
support groups, counselling, and respite care to help them manage their emotional and physical needs. may also benefit from
 Care planning: Developing
caregiver and other healthcare ateam
caremembers
plan that
canoutlines the patient's
help to reduce the needs, the roles and responsibilities of the
•Caregiver strain often goes
•unrecognized. In the hustle and bustle of a busy life, it may not be detected until the family caregiver suffers a health crisis
of their own.
•Interventions
•There are steps you can advise a family caregiver to decrease the caregiver strain. Advise them to
 Utilize in-home care services: Respite care to take a personal break, adult day care, counselling and
rehabilitation services on a routine basis to assist with the family member’s care.
 Seek financial help: If finances are an issue, approach an ASHA worker, who may advise you on available
resources to help bridge the gap. She may also refer to Village Health, Sanitation and Nutrition Committee/Jan
Arogya Samiti/ Mahila Arogya Samiti/ Resident Welfare Association who will ensure the availability of benefits
 from various governments and non-governmental programs/ schemes to the eligible patients/ caregivers.
Ask forIt and
needs. is accept help.
challenging to Many
do andfamily
can putcaregivers
both at feelfor
risk obligated
illness to injury.
or provideMake
all thea care
list and
of support
the task theircould
others lovedhelp
one
with and ask other family members to help with those specific chores.
 Set reasonable expectations for self and others. Care rendered may differ from person to person and should not
be criticized. Let the care given be good enough to keep the patient from risk for injury.
 Talk with the physician/nurse and make sure they know about the family caregiver. They may want to take extra
steps to protect the caregiver’s health, such as monitoring the blood pressure at home or prescribing a vitamin
 supplement.
Encourage self-care.
brisk walk five days a This
weekmay
and be
eat the mostdiet
a good difficult onethem
can help for family
to staycaregivers
healthy. to accept, but making time to take a
 Education and support: Providing caregivers with education about the patient's illness, trajectory, and symptom
management can help them better understand and cope with the situation. Caregivers
support groups, counselling, and respite care to help them manage their emotional and physical needs. may also benefit from
 Care planning: Developing
caregiver and other healthcare ateam
caremembers
plan that
canoutlines the patient's
help to reduce the needs, the roles and responsibilities of the
 • caregiver's burden and promote effective communication.
Providing
caregiver's support toand
symptoms theneeds,
caregiver:
such Recognizing
as pain, andand
anxiety, addressing the
depression,
can helpcare.
provide to promote their well-being and improve their ability to

•Overall, addressing caregiver strain in palliative care requires a

multi-disciplinary
and approach
the caregiver. that considers
By professionals the
providing education, needs of
support,both the patient
and caregiver
practical
assistance,
burden and healthcare
promote the well-being can
of help
both to
the reduce
patient and their
caregiver.
•• Conclusion
Palliative palliative
providing care focuses
care on preventing
patients with the and
best relieving
possible suffering
quality of and
life.
These patients typically experience multiple symptoms, the most
common ofnausea,
which are pain, depression, anxiety, fatigue, breathlessness,
insomnia,
management constipation,
helps functionality, diarrhea,
the person and
feel and anorexia.
moreof comfortable, Symptom
improving
physical well-being, quality life
 • LYMPHOEDEMA MANAGEMENT
•Introduction
•Lymphoedema is an accumulation of lymph in the interstitial space of subcutaneous tissue or is an excessive and persistent accumulation of extravascular and
extracellular fluid and proteins in tissue spaces. It occurs when lymph volume exceeds the capacity of the lymph transport system and is associated with the disturbance
of the water and protein balance across the capillary membrane.

•Pathophysiology
•Obstruction or damage blocks the lymphatic system with gradual dilatation of the lymph vessels leading to incompetent valves and increasing pressure inside the
vessels. The fluid tends to drain into the interstitial space by diffusion, resulting in lymph stasis.

•Classification of Lymphedema

1. Primary lymphedema: This type of lymphedema is caused by a congenital defect in the lymphatic
• system, leading to abnormal lymphatic drainage and fluid buildup.
• Congenital lymphedema: This type of primary lymphedema is present at birth or develops within the first two years of life.

2. Secondary Lymphedema: This type of lymphedema occurs as a result of damage to the lymphatic system, usually as a result of cancer treatment (such as
surgery, radiation, or chemotherapy) or infection.
• Cancer-related lymphedema: This is caused by cancer treatments that damage the lymphatic system, such as surgery or radiation therapy.
• Non-cancer-related lymphedema: This is caused by infections (such as filariasis) or other conditions that damage the lymphatic system, such as trauma or
surgery
•Signs and Symptoms of Lymphedema
Slow onset Swelling: Slow onset swelling is a common symptom in lymphedema, which refers to the gradual development
of swelling over time. Usually unilateral unless the disease/extensive trauma is present.
 Non-pitting oedema: Non-pitting edema is a type of swelling that occurs when pressure is applied to the affected area and
does not leave an indentation, as opposed to pitting edema, which leaves an indentation when pressure is applied. In people
with lymphedema, non-pitting edema is a common symptom that occurs due to the accumulation of lymphatic fluid in the
affected limb or area.
 Skin changes: dry, thickened skin, deep creases. Peaud's orange appearance,
 Stemmer's sign: inability to pinch a fold of skin at the base of the second digit.
 Hyperkeratosis: thickening of the outer layer of the skin, known as the epidermis. In people with lymphedema,
hyperkeratosis can occur as a result of chronic swelling, which can cause skin changes and thickening over time.
 Papillomatous lesion: abnormal growths or warts that can occur on the skin's surface in people with lymphedema. These
growths can develop in areas of the skin that are affected by lymphedema due to chronic inflammation, poor lymphatic flow,
and impaired immune function.
 Lymphorrhoea: lymphatic fluid leaks from the skin's surface due to damage or obstruction of the lymphatic vessels. The
lymphatic fluid is a clear fluid that circulates throughout the lymphatic system and plays a crucial role in immune system
function.
 Joint stiffness and muscle strain
 Discomfort, heaviness, and pain
•Some of the problems that people with lymphedema may face include:
Swelling: The most common symptom of lymphedema is swelling in the affected limb or area, which can cause discomfort, heaviness, and
limited mobility.
 Infection: The accumulation of lymphatic fluid in the affected area can create a breeding ground for bacteria, leading to infections such as
cellulitis or lymphangitis.
 Skin changes: Lymphedema can cause changes to the skin in the affected area, such as thickening, hardening, or discolouration, which can
make it more susceptible to infections, ulcers, or wounds.
 Reduced flexibility: Swelling and stiffness in the affected limb or area can reduce flexibility and range of motion, making it difficult to
perform daily activities or exercise.
 Pain: Lymphedema can cause pain and discomfort in the affected limb or area, affecting the quality of life and leading to depression or
anxiety.
 Emotional impact: Living with lymphedema can be challenging, and it can affect a person's emotional well-being, self-esteem, and
body image.
 Financial burden: Lymphedema treatment, such as compression garments, bandaging, or manual lymphatic drainage, can be expensive and
•. may not be covered by insurance, which can create a financial burden for people with lymphedema.
•Psychological issues
• Altered body image
• Anxiety and depression
• Reduced adjustment to illness
• Difficulty in wearing clothes
• Reduced working capacity
• Reduced social contact
 • In cancer, fear of recurrence

•Aim of lymphoedema care

• To maintain a healthy tissue condition

• To reduce the risk of infection, Daily care
• Meticulous hygiene
• Inspection of the limb and adjacent trunk
• Moistening of limb and adjacent trunk
•Four cornerstones of management
1. Skincare
2. Compression (bandage/hosiery)
3. Massage
4. Exercises

1. Skincare: Proper skin care is essential in managing lymphedema. People with lymphedema are at higher risk of skin infections, so keeping the skin clean and moisturised can prevent bacterial infections and reduce the risk of skin breakdown.

•Health Teaching for Skin Care

• Wash the affected arm with water.
• Keep the skin clean and moist.
• Do not use too much soap, which will dry the skin. Use only mild soap.
• Give special attention to creases between digits and joints.
• Avoid perfumes.
• Pat dry with a soft, clean towel.
• Do not rub the affected limb.
• Apply coconut oil from the distal to the proximal end of the limb.
• Use loose clothing.
• Avoid
o Injections in the swollen arm, including blood sampling
o Blood pressure measurement on the swollen arm.
o Vene punctures
o Jewellery on the affected limb
o Injury to the limb
o Lifting heavy weight
o Mosquito bites
• Take care when cutting toe nails or fingernails using a nail cutter.
• Treat cuts, scratches insect bites promptly by cleaning well and applying antiseptic cream or solution.
• Seek medical aid if the skin becomes red and inflamed.
• Protect from direct heat/sunlight.
• If lymphorrhoea or any injury, clean with saline and apply a sterile dressing.
• If cellulitis – do not start lymphedema care, treat cellulitis.
• 2. Compression. Compression therapy involves applying pressure
to the affected area to reduce swelling and improve lymphatic flow.
This can be achieved through various techniques, such as wearing
compression garments, bandaging, or pneumatic compression devices.
Compression therapy helps to maintain the reduced size of the limb
after it has been reduced by manual lymph drainage
•Benefits of Compression
• Improved lymph drainage.
• Improve movement and function of the limb.
• Improve distorted limb shape.
• Improve thickened fibrotic skin.

•Bandaging: Bandaging in lymphedema involves wrapping the

affected limb
compression. Theor area with specialised bandages designed to provide
•bandages are applied in a specific sequence,
starting
upward, atto the base of lymphatic
encourage the limb fluid
and working
to flow
towards
to the trunk.
provide more The bandages
compression at are base
the designed
of the
limb and gradually
they move upward decrease in compression as
•The duration and frequency of bandaging will depend on the severity of
the lymphedema
bandages may be and for
worn the several
individual's
days specific
or weeks needs.
at a time In
andgeneral,
should
be changedalso
Bandaging andhelps
re-applied
limit by aaccumulation
fluid trained healthcare
in the professional.
subcutaneous
tissue
lymphand provides the muscles with a firm outer casting by stimulating
flow.
•Principles of bandaging
 • Apply graduated pressure.
• Reshape limb in a cylindrical manner with cotton and gamgee pad and crepe bandage.
• Apply for 24 hrs (most preferred)
• Low resting pressure increases during exercises.

•Procedure
• Wash and dry the limb carefully.
• Manual lymphatic drainage has to be done before bandaging.
• Moisturise with coconut or moistening cream before bandaging.
• Artiflex cotton padding is done to bring the limb into a cylindrical shape.
• Short stretched small, width bandages are applied from the distal to the pommel end of the limb.
•Post bandage assessment
•After a bandaging session for lymphedema, it is essential to perform a post-bandaging assessment to evaluate the
effectiveness of the involves
assessment typically treatmenttheand identify steps:
following any potential issues that may need to be addressed. The post-bandaging
1. Measure the limb: Measure the circumference of the affected limb at specific points, such as the
• ankle, knee, or wrist, to evaluate the degree of swelling reduction achieved by the bandaging.
2. Inspect the skin: Inspect the skin for any signs of irritation, redness, or skin breakdown. Any areas of concern
should be documented and monitored closely.
 3. Check for proper fit: Ensure that the bandages are properly applied and do not cause discomfort or constriction. The patient should be asked if they are
experiencing any pain or discomfort, and the bandages may need to be adjusted if necessary.
4. Evaluate range of motion: Evaluate the patient's range of motion and functional abilities to assess the impact of the bandaging on their mobility.
5. Plan for ongoing care: Based on the results of the post-bandaging assessment, the healthcare provider can develop a plan for ongoing lymphedema
management, which may include additional bandaging sessions, compression garment therapy, manual lymphatic drainage, or exercise.
6. Report to doctors and remove the bandage immediately if any of the following is noted.
 Pain (pins and needles)
 Numbness
 Discoloration of toes and fingers

•Hosiery
•Hosiery, also known as compression stockings or compression garments, is a common treatment option for
lymphedema. Hosiery is designed to provide graduated compression to the affected limb, which helps to reduce swelling
and improve lymphatic flow. Hosiery is easy to use and can be worn during daily activities.
•Indication for hosiery application
 The limb shape is not distorted.
 Mild oedema
 No deep creases
 Skin is tough enough to cope with hosiery.
 No lymphorrhoea
• NB: Hosiery is removed at bedtime.
• Fig. 4.15: HOSIERY

3. Massage: Lymphatic massage is the procedure used to encourage lymphatic fluid away from swollen, congested body areas to areas where it can drain away
normally. Lymphedema massage, also known as manual lymphatic drainage (MLD), is a type of massage therapy that is used to help reduce swelling and improve
lymphatic flow in individuals with lymphedema. It is a gentle, hands-on technique that uses specific movements to stimulate the lymphatic system and encourage the
movement of lymphatic fluid out of the affected area.
•Aim of Massaging
• To stimulate contractions of superficial lymphatics
• To facilitate lymph flow from congested to non-congested areas

•Contraindications for Massaging

 Acute cellulitis /erythema
 Renal failure
 Deep Vein Thrombosis
 Unstable hypertension
 Severe cardiac insufficiency
 Hepatic cirrhosis with ascites
 Superior vena cava obstruction
•Techniques

• Keep the patient in a relaxed and comfortable position(lying/sitting)

• While massaging, always clear non-swollen side first to clear the way ahead.
• Use dry hands while performing massage. Cream or powder should not be applied.
• The patient should ideally wear compression garment during massage.

• For head and neck swelling work with nodes at back and front of neck, under chin, occipital nodes, cheeks and lips.

4. Exercise: Exercise can be a helpful component of a comprehensive lymphedema management plan, as it can help improve lymphatic flow and reduce swelling.
However, it is important to approach exercise cautiously and work with a healthcare professional or therapist familiar with lymphedema management to ensure that
exercise is safe and appropriate for your individual needs. Exercise reduces soft tissue oedema and improves joint mobility, enhancing the lymphatic pump's efficiency.
Wearing a compression bandage during exercise enhances lymph flow and protein re- absorption more efficiently.
•Aim of exercise
 To encourage regular activity e.g., walking
 To prevent stiffness.

•Assessment before exercise

• Posture
• Joint range
• Muscle power
• Function
• Ease of movement.
• Changes in sensation.
•Exercise for Swollen Arm
• Patient should be sitting comfortably and arm stretched out at a level with shoulder supported
• along its length on a pillow.
• The best way to exercise is while wearing a compression garment or bandage.
• Stretch fingers out. Hold for 5 seconds then relax (20 repetitions).
• Make a strong fist. Hold for 5 seconds then relax (20 repetitions).
• Point fingers down towards the floor bending at the wrist. Hold for 5 seconds then relax (20 repetitions).
• Bend hand up pointing fingers towards the ceiling.
• Hold for 5 seconds then relax (20 repetitions).
• Slow circular clockwise and anti- clock-wise movements at wrist joint (20 repetitions each).Stretch fingers out. Raise
arm bending at elbow. When arm is fully bent, make a tight fist and twist hand so that palm faces body (supination).
Hold for 5 seconds then relax (20 repetitions).
•Exercise for Swollen Legs
• These exercises are best done lying on the floor with the legs raised on pillows or cushions.
• Slowly and firmly rotate the feat, making a circular movement with pointed toes.
• Slowly and firmly point your foot towards the floor, then bring it back as far as it will go.
 • Slowly and firmly, bring your knees up to the chest.
• Slowly straighten your legs and lower down to the pillows.
• Bring knees up to chest slowly and firmly to do bicycling movements.
•Health Education
• Limb elevation is achieved by using 2-3 pillows while lying on the bed.
• Make sure the limb is straight and above the heart level.
• Do not dangle the legs if swollen
• Avoid crossed legs.
• Exercise is to be performed every day, morning and evening.
• Active and passive range of movement exercises.
• A slow and rhythmical rest period must be followed.
• All joints in the affected quadrants will be moved through the pain-free range.
• Exercises are done within the ability of the patient.
• Optimization of care refers to improving the quality of healthcare
services and increasing
• efficiency. Optimization of care in end-of-life care involves ensuring
that patients receive the
• best possible care to meet their physical, emotional, social and
spiritual needs. This may involve
• a range of interventions, including pain and symptom management,
emotional support, and
• spiritual care.
• Key aspects of optimization of care
• • Communication between patients, families, and healthcare professionals: This may
• involve discussions about end-of-life care planning, including decisions about lifesustaining
• treatments, advance directives, and goals of care. By facilitating open and
• honest communication, healthcare professionals can ensure patients receive care
• consistent with their wishes and values.
• • Use of evidence-based interventions to manage symptoms and improve quality of
• life: This may involve using medications, such as opioids or other pain relievers, as well
• as non-pharmacological interventions, such as massage or other forms of complementary
• therapy. By using evidence-based interventions, healthcare professionals can ensure
• patients receive safe, effective, and appropriate care.
• Addressing the emotional and spiritual needs of patients and their families: This may
• involve counseling, support groups, or other forms of therapy to help patients and families
• cope with the challenges of a terminal illness. Chaplains or other spiritual leaders may
• also be available to provide spiritual support or guidance. Optimization of care also
• involves providing care that is culturally sensitive and respectful. This may involve
• understanding and respecting patients' and families' cultural beliefs and practices and
• incorporating these beliefs into the care plan.
• • Patients receive coordinated and integrated care across different settings, such as
• hospitals, hospices, and home care: By working together as a team, healthcare
• professionals can ensure that patients receive seamless, high-quality care that meets their
• needs and preferences. It is crucial to evaluate, acknowledge and optimize the total needs
• of patients with a terminal illness and their families with early, honest and empathetic
• communication. For caring to happen, we must understand the patients' and their families'
• needs and priorities. Making individualized shared decisions aiming at "Quality of Life"
• would be considered an appropriate line of management.
• As nurses, we should facilitate to take shared decisions based on discussions
with the
• patient and family. The decisions to be taken are regarding goals of care,
emphasizing what is
• "quality of life" for them and not what we decide based on organ function.
The five priorities
• focus on: recognizing that someone is dying; communicating sensitively with
them and their
• family; involving them in decisions; supporting them and their family; and
creating an individual
• plan of care that includes adequate nutrition and hydration.
• Essential components of optimization of care
• 1. Quality of life
• 2. Essential care
• 3. Anticipatory prescription
• 4. Dying with dignity
• 5. Care during the terminal phase
• 6. Ethics-based decision making
• 1. Quality of life
• Quality of life (QOL) is defined by the World Health Organization as "an individual's
• perception of their position in life in the context of the culture and value systems in which they
• live and in relation to their goals, expectations, standards and concerns. Quality of life is the
• degree to which an individual is healthy, comfortable, and able to participate in or enjoy life
• events. Quality of life is a broader concept concerned with whether disease or impairment limits
• a person's ability to fulfil a normal role (for example, whether the inability to climb stairs limits
• a person at work). The feeling of being at peace and having a sense of meaning in life is more
• important to patients than being active or physical comfort, and spiritual well being.
• Quality of life is a dynamic concept that may change throughout illness and treatment. The
• definition of quality of life is subjective as individuals have very personal descriptions of their
• concept of quality of life. People also differ in the importance they place on various aspects of
• illness, which causes a differential impact on the experience of life. Different responses about
• perceived QOL may be observed even in people with the same clinical condition. Therefore,
• ensuring the quality of life represents a challenge because cultural, ethnic, religious and other
• personal values determine how the quality of life is judged.
• 2. Essential care
• Essential care in end-of-life care focuses on providing comfort and support to patients as they
• approach the end of their lives. The goal is to ensure that patients can live their remaining
days
• with dignity and respect and minimize their physical and emotional suffering. Essential care
in
• end-of-life care involves a multidisciplinary team of healthcare professionals, including
doctors,
• nurses, social workers, chaplains, and other specialists. The team works together to provide a
• range of services that address the patient's and their family's physical, emotional, and
spiritual
• needs.
• Social support is also an important aspect of end-of-life care. It may involve connecting patients
• and their families with community resources, such as hospice services, home care services, or other
• programs that can provide practical support and assistance.
• In summary, essential care in end-of-life care involves a holistic approach that addresses the
• physical, emotional, and spiritual needs of patients and their families. By providing compassionate
• and comprehensive care, healthcare professionals can help patients live their remaining days with
• comfort, dignity, and respect.
• 3. Anticipatory prescription
• Anticipatory prescribing is a practice in end-of-life care where medications are prescribed in
• advance to manage symptoms that may arise as a patient's condition deteriorates. Anticipatory
• prescribing aims to ensure that patients receive prompt and effective treatment for symptoms without
• unnecessary delays or discomfort. Anticipatory prescribing enables prompt symptom relief at
• whatever time the patient develops distressing symptoms. Anticipatory prescribing means
• ensuring that someone has access to medicines they will need if they develop uncomfortable
• symptoms at home or in a care home. The medications are prescribed in advance so that the person
• can access them as soon as needed.
• Physical care is an important aspect of end-of-life care and may involve pain management,
• symptom control, and other interventions to ensure that the patient is comfortable. Patients may be
• taking several medications. Essential medications such as anti-hypertensive, hypoglycemic agents,
• anticoagulants, etc. must be reviewed. Considering the patient's poor food intake, cachexia, and
• hemodynamic status, except for the essential medications, the rest must be discontinued. This may
• include using medications, such as opioids or other pain relievers, and non-pharmacological
• interventions, such as massage or other forms of complementary therapy.
• 129
• Emotional support is also a crucial component of end-of-life care. It may involve counselling,
• support groups, or other forms of therapy to help patients and their families cope with the challenges
• of a terminal illness. Chaplains or other spiritual leaders may also be available to provide spiritual
• support or guidance.
• Social support is also an
• Although each patient has individual needs, many acute events during the palliative period
• can be predicted, and management measures put in place. Before discharge from the unit, patient's
• families must be empowered to manage issues like dyspnea, panic attacks, delirium, pain, extra. A
• clear discharge summary and medications need to be provided for each symptom. If the family needs
• any assistance linking with local general practitioners to support the family will be helpful.
• 4. Dying with dignity
• Dignified dying: Dignified dying refers to the process of dying with respect, compassion, and
• comfort, while maintaining the patient's autonomy and dignity. The goal of dignified dying is to
• ensure that patients are able to die on their own terms, with their physical, emotional, and spiritual
• needs addressed in a compassionate and respectful manner. It is a natural death free from avoidable
• distress and suffering for patients, families and caregivers, following the wishes of patients and
• families and consistent with clinical, cultural and ethical standards
• Key aspects of dignity in end-of-life care are:
•  Respect, which includes self-respect, mutual respect, and respect for privacy.
•  Autonomy involves having and providing choices, as well as competence and independence.
•  Empowerment can involve self-esteem, pride, and modesty.
• 5. Care during the terminal phase
• The terminal phase is when day-to-day deterioration occurs, particularly of strength, appetite, and
• awareness. At this phase, nurses must ensure the patient's comfort physically, emotionally, and
• spiritually and make the end of life peaceful and dignified. We can also make the memory of the
• dying process as positive as possible for those left behind by our care and support.
• End of Life Care (EOLC) is the way of caring for a terminally ill patient that shifts attention to
• symptom control, comfort, dignity, quality of life and quality of dying instead of trying to cure or
• increase the life.
• Recognizing the terminal phase
• Remember, these signs and symptoms are very common, but wide variations can
occur, so it is
• 130
• impossible to predict accurately.
• • Increasing weakness, the patient becomes bedbound
• • Loss of interest in surroundings and food
• • Difficulty in swallowing
• • Drowsiness
• • Cool hands and feet
• • Change in breathing (jerky, noisy, very slow, gasping)
• Goals of care
• • Explaining and communicating with caregivers so that they are mentally prepared.
• o Find out how much they understand.
• o A person important to them should be present during the discussion.
• o Find out if they wish to know more about the prognosis and discuss it accordingly.
• o Address their fears and concerns.
• o Provide contact information (ambulance, your contact, nearest doctor, hospital, etc.)
• o Find out if they have any religious, cultural, social or spiritual needs.
• o Explain the uncertainty about the exact time of death.
• o Document the discussion along with the names of the persons discussed.
• o Discuss the case with the doctor concerned and document it
• o Make the patient as comfortable as possible.
• o Give 'individualized care'.
• o Assess the level of consciousness.
• o Find out the patient's wishes.
• o Record and document preferred place of care (home, hospital, etc.)
• o Find out the wishes of the caregivers.
• o Remember! the wishes and plans may change.
• Giving Fluid
• If swallowing is difficult, feeding with a spoon is helpful. Ensure that the first sip is swallowed
• before the next sip.
• • Discuss the risk of aspiration.
• • Encourage caregivers to give lip and mouth care.
• • What the patient can be given depends on the level of consciousness, ability to swallow, and
• level of thirst.
• • Adverse effects of Intravenous fluids
• o Difficult at home
• o Expensive
• o Needs supervision
• o Infection can occur
• o Fluid can collect in the lungs.
• Review
• • All medicines taken by the patient need to be reviewed with the
doctor and find out if any
• 'non-important' medicines can be stopped.
• • The doctor will decide on the best route for the medicines.
• • Intramuscular and intravenous routes are avoided.
• • Subcutaneous injections can be used.
• • Regular review is needed
• Good symptom control
• • Provide 'non-drug' methods of symptom control.
• • Control of pain: continue pain medicines after discussion with the doctor.
• • The patient is likely to pass urine and stool in bed. The caregivers should be taught
how to
• clean the patient.
• • After discussion with the caregivers and doctor, catheterization may be needed.
• • If the patient cannot swallow, a feeding tube can be inserted after discussion with the
doctor
• and with the consent of the patient and/or caregivers. The caregivers should then be
taught
• how to administer nasogastric feeds.
• Breathlessness
• ▪ Consider non-pharmacological methods
• - Switching on the fan
• - Staying with the patient and boosting morale
• - Gently stroking the back
• ▪ Do not start oxygen therapy routinely without discussing it with the doctor
• ▪ Consider drug therapy (Morphine, alprazolam) after discussing with the doctor and document
• Anxiety, restlessness, and confusion
•  Look for causes like pain.
•  Ask the doctor for medication.
•  Noisy secretions (death rattle) are due to collected secretions at the back of the throat when
• the patient is too weak to swallow them. They do not cause discomfort to the patient, but
• relatives may be worried that he is choking or in pain.
•  Explain to caregivers that it does not cause distress to the patient.
•  Try non-drug measures.
•  Place the patient in the recovery position.
•  Remove the secretion from the angle of the mouth using a finger wrapped in a gauze
• piece by 'hooking' the finger and 'swiping'.
•  Ask the doctor for medication.
• Seizure
• • Prevent the patient from self-harm. Do not force any object, like a spoon, into the mouth
• • If possible, give intravenous, subcutaneous, or intramuscular Midazolam or any other drug
• suggested by the doctor.
• • Continue anti-epileptics as prescribed.
• Severe bleeding
• • Plan for this possibility and discuss it with the family in advance.
• • Apply firm and steady pressure wherever possible using dark towels or bed sheets.
• • Sedate the patient quickly with intravenous, subcutaneous or intramuscular midazolam or
• any other drug suggested by the doctor.
• Supporting the Family
• • The family will be suffering physically, emotionally, socially and spiritually. Hence
• address these issues and support accordingly.
• • Address religious, social and spiritual needs.
• • Arrange extra help, including help from a doctor
Dying phase
• The last 48 hours is crucial in caring for the person, family and caring
team. There is
• only one chance to “get it right”, and when things do not go well,
families and staff
• can be left with long-term guilt and regrets.
• The key to "getting it right" is anticipating that this stage has been
reached. Carers who regularly
• look after the patient and spend the most time with the patient
intuitively pick up subtle signs of
• deterioration. They are often entirely accurate at predicting the
approaching death than
• professionals.
• Symptoms Signs
• Profound weakness/bedbound Gaunt appearance
• Needs assistance for basic needs Drowsiness
• Diminished intake of food and fluids Loss of skin turgor
• Disoriented in time, place and person Dry mouth and conjunctiva
• Difficulty in concentrating and
• cooperating
• Cold extremities
• Care of Dying
• Caring for the dying is not only based on scientific principles but it is an art. Unfortunately, the
• concept is not dealt with due to its importance during the training of nurses. As a result, most
• traditionally trained nurses cannot provide the necessary care when confronted with dying patients.
• With adequate training and simple measures, good quality care can be given to these patients and
• their family members. Providing comprehensive and holistic care will give a sense of satisfaction
• for the caring team.
• The changes that occur before death
• The dying process is unique to each person, but in most cases, there are common characteristics or
• changes which indicate if a person is dying. Anyone of these signs can be attributed to something
• other than dying, so remember that the events described here are happening to a person whose illness
• is already so severe that life is threatened.
• The main changes are:
• Decreased intake:
• • As a person approaches the End of Life (EOL) phase, the body's nutritional requirement
• decreases drastically. So, the person may have decreased appetite and decreased thirst.
• • It is essential to remember that this is a natural process and not distressing to the patient. But it
• may be uncomfortable for the family caregivers to see the patient not eating or drinking fluids.
• • Reassuring and encouraging them to provide sips of water and applying moist swabs on their
• lips can promote the patient's comfort. On the other hand, forcing feeds may increase the
• patient's distress with little to no benefit.
• Increasing weakness:
• • As the person moves closer to death, weakness becomes more and more profound.
• • As the weakness increases, general activity decreases.
• • Towards the late terminal stage, they may find it challenging to continue conversations
• and even tolerate personal care.
• • The goal at this juncture is to avoid routine care that makes the person uncomfortable and
• provide care aimed at improving comfort.
• Increasing drowsiness:
• • As patients drift into the End-of-Life phase, they become increasingly tired, drowsy, and
• difficult to arouse—the time they spend sleeping increases gradually.
• • There may be decreased speech, and they may appear withdrawn.
• • In some patients, there may also be confusion, inability to recognize people and restlessness.
• • Terminal delirium and restlessness can be effectively managed by Haloperidol or
• Benzodiazepines based on the cause.
• • Family caregivers should be advised to talk to the patient when the patient is fully alert and
• talk calmly and gently.
• Changes in respiration:
• • As a person approaches the terminal phase, respiration becomes shallow.
• • Some patients' respiratory rate may increase, but respiration usually becomes shallow
• and spaced out.
• • Jaw breathing can be seen in some patients.
• • Carers should be reassured that this is a typical dying process that is not distressing to the
• patient.
• • Another distressing symptom for the family carers to watch is the 'death rattle'. It occurs
• due to salivary secretion and mucus accumulation at the throat as swallowing and
• coughing reflexes disappear during the end-of-life phase.
• • The gurgling sound produced by the oscillating Fluid with each respiration can be
• distressing to the carers but not the patient.
• • It can be managed effectively by turning the patient to the sides and draining the
• secretions. Anticholinergic like Glycopyrrolate given sublingually or subcutaneously can
• reduce these secretions.
• • The collected secretions should be drained first as these drugs only prevent further
• accumulation
• Temperature:
• • During the terminal stage, the body temperature drops. This may be due to reasons like
• decreased metabolism and slowing down circulation.
• • The feet and hands may appear pale, cold and clammy.
• • An extra blanket may be required if the person indicates that they are feeling cold.
• • At this point, the room should be well-ventilated and less crowded.
• Changes in excretion:
• • Urinary and faecal incontinence is observed in only a few patients during end-of-life phase.
• • The urinary output decreases drastically; the urine may appear dark and brown.
• • There may be oedema due to fluid retention.
• • It is vital to keep patients' comfort as apriority at this point.
• • Maintaining good perineal hygiene and preventing pressure sores are crucial to
• maintaining comfort.
• Nursing Management
• Allow the family to voice their concerns. Clarify expectations and prognosis. Ask the family if they
• wish to take the patient home or continue terminal care in the hospital.
• • Check if appropriate medicines have been ordered for troublesome symptoms, e.g. pain and
• breathlessness, according to palliative policies and relevant to the care setting (home/
• hospital.)
• • Check if inappropriate interventions need to be tapered or discontinued.
• • Encourage the family to support the primary caregiver and allow them respite.
• • Check that nursing care for the patient with attention to oral hygiene and skin, bowel and
• bladder care is continued.
• • Remain sensitive to changes in the patient's and family's physical and emotional needs.
• Care in the Terminal Phase
•  Allow the family to voice their concerns.
•  Clarify expectations and prognosis.
•  Involve the Counsellor or Chaplain/ religious representatives like Panditji, Priest, Maulavi or as
• preferred
• Signs of approaching death
• • Facial appearance: Facial muscles relax; cheeks become flaccid, moving in and out with each
• breath.
• • Change in sight, speech and hearing: Sight gradually fails. The pupils fail to react to light.
• Eyes are sunken and half-closed, and a film appears over the eyes. Speech becomes
• increasingly difficult, confusing, disoriented, slurred and finally impossible. Hearing is
• thought to be retained longer.
• • Change in the Respiratory System: Respiration becomes irregular, Cheyne stokes, rapid and
• shallow, or very slow and noisy due to secretions.
• • Circulatory system: - Pulse becomes slow then stops. There is a fall in BP.
• • Gastrointestinal System: Nausea, vomiting and abdominal distension are present. The patient
• may find it difficult to swallow. Patient's appetite gradually decreases, and they stop or refuse
• to eat and drink. The nurse should not force the patient's family to feed the patient. Offering
• them ice pops helps them to stay hydrated.
• • Skin and Musculoskeletal System: The skin may become pale, cold and clammy. Muscle
• tone is lost.
• Excretory System: bowel or bladder incontinence or both.
• • Central nervous System: Reflexes are gradually lost. The patient may be restless, confused
• and may have altered sensorium.
• • Hallucinations: It is not unusual for a dying person to experience hallucinations or distorted
• visions. It is best not to correct them about these visions, as doing so may cause additional
• distress. Although this may seem concerning, the nurse can provide reassurance and should
• explain to the families.
• The psychological needs of a dying person
• • Relief from loneliness, fear, and depression.
• • Maintenance of security, self-confidence, and dignity.
• • Maintenance of hope.
• • Meeting the spiritual needs according to his religious customs.
• Care of the dying person
• • Provide psychological support to the patient and the near and dear ones. Be warm, supportive
• and understanding. Do not whisper in the patient's vicinity, which may increase fear.
• Provide privacy, as it will help prevent adverse effects on other patients.
• • Need to think about oxygen therapy, IV Fluids and NGT feed, as in palliative care for dying
• patients, these interventions may not be helpful.
• • As the patient may have incontinence, keep him dry and comfortable. The patient can be
• catheterized. Use pads.
• • Provide routine skin care and maintain hygiene.
• • If the patient has pain, provide analgesics or other drugs for relief.
• • If the patient or relatives desire to perform religious rites, permit them to do so. Depending
• upon his religious faith, the patient may welcome a visit from a Panditji, Priest, Maulvi or as
• preferred.
• Care of body after death Diagnosing and declaring death
• • Any doctor, preferably from the palliative care unit, can certify death
• • Inform the relatives
• • Certify death & fill in the necessary forms
• • Assist the family in decisions regarding transportation, embalming, mortuary care, etc.
• Criteria for declaring death
• • Apnea
• • Absence of mechanical cardiac activity (absence of heart sounds on auscultation & absence of
• central pulses on palpation)
• • After 5 minutes, check for the following:
• o Absence of pupillary light reflexes (pupils non-reactive to light and fixed)
• o Absence of corneal reflexes (remove contact lenses)
• o Absence of motor response to supraorbital pressure/pain
• • If the above features are fulfilled, death can be declared. The time of death should be noted.
• The record should be signed and dated with the ID number.
• Last office/death care is like any other case in a hospital or home Last office/death care
• Purpose:
• • To maintain normal body alignment before rigor mortis sets in
• • To prepare the body for transport to mortuary/residence
• • To reduce mental distress of family
• Articles
• A tray with
• • Long artery clamp
• • Bandage
• • Non-absorbent cotton
• • Absorbent cotton
• • Mortuary card in transparent plastic cover
• • Towel
• • Hospital gown or patient's clothes draw sheet
• • Long mackintosh
• • Equipment needed for bath
• Procedure
• • If there are oral secretions, turn the patient to the side and drain the secretions.
• • Eyes should be closed by applying light pressure for 30 seconds
• • Remove all internal devices like urinary catheters, nasogastric tubes and intravenous catheters
• on the puncture site and wound to prevent leakage and soiling.
• • Make the deceased lie supine and straighten all the joints. When rigor mortis sets in, manipulating
• the joints become difficult; hence all the joints should be straightened early.
• • Place a pillow under the head. This keeps the alignment and holds the jaw closed.
• • Since the final bath is included as one of the last rites of the deceased, discuss it with the family
• • Wash the person's face, gently closing the eyes before beginning, using the soft pad of the
• fingertip. Close them and hold them in place for a few minutes following death. They may stay
• closed on their own. If they do not, close them again and place a small soft cotton pad over them.
• • Use saline-moistened gauze if corneal or eye donation is likely to take place.
• • Clean the mouth and replace dentures after death as soon as possible. Do not remove dentures
• because you may have difficulty replacing them as the body stiffens. If dentures cannot be
• replaced, handover to the family in an identified receptacle.
• • Keep the jaw closed by placing a towel roll under the chin or preparing a jaw strap with a bandage
• tied loosely around the head. If the strap is too tight, it can leave pressure marks.
• • Tidy the hair and arrange it into the preferred style, if known
• • Shaving too soon after death can cause bruising, which may be done later. Explain this to the
• family if they request shaving. Remember, some faith groups prohibit shaving
• • Clear leaking or secretions from the oral cavity or tracheostomy sites by suctioning and
• positioning, then cover exuding wounds and unhealed surgical incisions with a clean absorbent
• dressing and secure with an occlusive dressing
• • Pack nose and mouth with Non-absorbent cotton using forceps.
• • Pack the anus and vagina (if female) with Non-absorbent cotton.
• • As the sphincter relaxes, urine and faeces may leak; placing absorbent cotton pads will prevent
• soiling.
• • Clean and dress the deceased person appropriately. Clean the body using a facecloth with water
• and a small amount of soap. Begin with the arms and legs and then move to the front and back of
• the trunk. Take assistance from someone to roll the person to each side to wash the back. Fragrant
• oil may be added to rinse water. Dry one part of the body before moving to another. Some families
• or cultures may also apply a special lotion, oil or fragrance to the person's skin.
• • Dress or cover the body according to personal wishes or cultural practices.
• • Remove all valuables in the presence of another staff member and document this. If any jewellery
• is removed, provide a signature while handing over this to relatives. Document jewellery as
• yellow metal or white metal and never as gold or silver
• • Bring hands over the chest. Interlace fingers and tie the two thumps together with a bandage (or
• according to their preference).
• • Attach one tag to the wrist. Ensure the deceased person is identified with a name band on the
• wrist.
• • Bring the legs together and tie the great toes together.
• • Wrap the body with a sheet. Using the clean sheet placed under the patient, wrap the body and
• secure all limbs within the sheet. Ensure that the feet are also covered, and then cover the face.
• Apply tape to secure the sheet. Attach the other tag at the center.
• • Clear the room of unnecessary clutter and use a clean cloth to cover the patient.
• • Cover the prepared body with a sheet and notify the nurse I/c. Call for the messenger to take the
• body to the mortuary with a copy of the death certificate.
• After Care
• • Honour the deceased and their family's religious or cultural wishes/requirements while
• meeting legal obligations
• It is essential to give time and space to the family to grieve over their loved one. Offer
• support to the family through quiet and compassionate presence, active listening and gentle
• touch.
• • Offer support to the family through quiet and compassionate presence, active listening and
• gentle touch.
• • Ensure the deceased privacy and dignity.
• • Ensuring the health and safety of everyone who comes into contact with the deceased is
• protected.
• • Replace the articles used for death care.
• • Returning the deceased's possessions to the next of kin.
• • Screen off the patient's bed area while the removal of the body takes place to avoid causing
• distress to other patients
• • In most hospitals, the body is never handed over to relatives directly. It is always dispatched
• to the mortuary
• • Send the body to the mortuary with a death certificate as soon as possible
• • Send information about the death to all concerned
• • If the nurse provides death care, document the same
• • If there is a risk of infection, a body bag should be used and a hazard label must
• be attached to the body bag and any accompanying documentation. Some hospitals use body
• bags for all deceased patients, so follow the hospital policy and SOP of the institution.
• • Ensure that the patient's belongings are handed over to the patient's family and document the
• same.
• • Plan for bereavement support visits and document the same in the case sheet
• Documentation: The nurse should write a detailed report on the death, including the:
•  The time
•  Who was present/ declared dead
•  The nature of the end
•  Details of any relevant devices or treatments
•  Death care provided by
• Care of unit after death (if in hospital):
• • Dispose of used equipment according to hospital policy. Use clinical waste bags to dispose of
• any waste considered infectious or hazardous. To reduce the risk of cross-infection, wash
• hands thoroughly and decontaminate hands by using alcohol hand gel
• • Terminal disinfection of the unit should be done as per hospital policy
• DEATH CARE AT HOME
• What to do in the event of death?
• In a clinical setting, a doctor is required to confirm and declare death. Nurses are not authorized to
• do that. But when death occurs at home, the practice of confirming death differs in different states.
• It will be prudent to follow the policy of the state when such an event occurs.
• General guidelines:
• 1. No matter how much the family is prepared to accept death, it is painful. Giving
• Giving the family
• time and space to grieve over their loved one is very important. The first hour after death can
• be very peaceful. Family can feel sadness and a deep sense of relief, especially if the patient
• has 'suffered'.
• 2. If possible, encourage the family to have time and space
• 3. Record the time, nature of death, who was present and details of death confirmation in the
• 138
• patient's case sheet.
• 4. While performing post-death care, discuss patient and family preferences and local cultural
• practices to be followed.
• 5. Ensure that privacy and dignity are provided to the deceased and the family while providing
• death care.
• 6. If the family wishes, allow the family to be involved in the deceased's post-death care.
• 7. If the nurse provides death care, document the same in the patient's case sheet.
• 8. Homecare team members should wear appropriate personal protective equipment and follow
• standard precautions while providing death care. If there is a potential source of infection,
• advise the family caregivers to wear PPE. (Refer to the chapter on Standard precautions)
• Bereavement Support for the family
• • Palliative care does not stop with the patient's death. It continues after the patient's death in
• the form of bereavement support for the family.
• • After the death, pay a bereavement visit to the family.
• • Collect back any unused opioids and hand them to the palliative team.
• • The family may need support for a few months after the death
• • People may grieve for six months to one year after death and then slowly resume normal life
• • Some people may find it very difficult to accept, especially the death of an earning member
• or a child and go into depression. They will need a referral to a counsellor or psychiatrist.
• Grief
• Grief is the natural response to losing something or someone they hold or feel dear. Bereavement
• is the state of this loss. It affects a person's physical, social, spiritual and emotional states. Grief as
• a response to the death of a loved one is to be critically handled. Grief is naturally expressed by
• mourning (i.e., crying or talking about the loss). Understanding the process of grieving will help
• us to handle it better. There is no apt process of grieving or reacting to bereavement. It depends on
• many variables such as personality, nature of the relation, situational conditions and social supports
• available
• The support for grief should be ideally initiated before death. Any pharmacological intervention
• cannot suppress grief. A loss of a person with whom we have had a lot of memories will create a
• void that cannot be filled, leading to a lot of pain. This will be showcased in different ways.
• Stages of Grief
• Grieving is a normal process that usually begins before an anticipated death. The five stages of
• grief, also known as the Kubler-Ross model, is a widely recognized framework for understanding
• the emotional and psychological process that individuals may experience after a significant loss.
• These stages are not necessarily linear, and not everyone experiences them in the same order or
• at the same intensity. However, they can provide a helpful guide for understanding the grieving
• process:
• • Denial: In this stage, the individual may feel disbelief or numbness, and may have
• difficulty accepting the reality of the loss.
• • Anger: As the reality of the loss sets in, the individual may feel angry, frustrated, or
• resentful. They may lash out at others or at the situation itself.
• • Bargaining: In this stage, the individual may try to negotiate or make deals with a higher
• power or with themselves to avoid the reality of the loss.
• • Depression: This stage involves feelings of sadness, despair, and hopelessness. The
• individual may withdraw from social interactions and may struggle with daily tasks or
• routines.
• Acceptance: In this final stage, the individual comes to terms with the
reality of the loss
• and begins to find ways to move forward with their life. This may
involve developing a
• new sense of purpose or finding meaning in the loss.
STAGES OF GRIEF
• The grieving process is unique to each individual and can vary depending on factors such as
• personality, coping style, and cultural background. It is important to note that not everyone goes
• through all of these stages, and some individuals may experience additional emotions or reactions
• that are not included in this framework. If needed, it is also important to seek support from family,
• friends, or mental health professionals.
• In all these stages, the nurse needs to be truthful but prudent in all their dealings with the patient.
• Maintain a genuine, honest attitude of interest. Be warm, supportive and understanding. The patient
• may ask many questions and clarify many of his doubts. Let the patient tell you what he knows about
• his condition. Try to use his own words when talking to him.
• Points to remember:
• • It takes time to accept the loss, after which the person undergoes depression and slowly recovers.
• • The depression phase can be troubling, and the grieving person can even have suicidal
• tendencies or feel as if he is going crazy.
• • The mere presence of a person would be considerable support for the family. The time
• required for support may vary considerably from few days to years.
• • The foundation for supporting a person in grief is to listen.
• • Listening rather than speaking can help the person recover.
• • The nurse should motivate the grieving person to talk more about the death, enquiring about their feelings.
• • This would help them in accepting the loss and pain of bereavement. Never compare their losses
• with yours, and avoid remarks or platitudes.
• • Major changes in sleeping patterns, considerable differences in weight (loss or gain), feeling
• confused, inability to concentrate, and inability to stop crying are all associated with grief. If the
• person recognizes these problems and can talk about them, they will likely be able to recover in time
• Persistence of these symptoms for more than a few months, suicidal thoughts, thoughts of
• harming oneself or others, uncontrollable anger, or worries about one's behavior all indicate the
• need for professional help
• 6. Ethics Based Decision Making
• Ethics-based decision making in end-of-life care involves balancing the values and goals of
• the patient with the ethical principles of healthcare. The goal is to ensure that the patient's wishes
• 140
• are respected and that care is provided in a way consistent with the patient's values and beliefs.
• There are several ethical principles that guide decision-making in end-of-life care, including
• autonomy, beneficence, non-maleficence, and justice. Autonomy refers to the patient's right to
• make decisions about their care, while beneficence refers to the obligation to do good for the
• patient. Non-maleficence requires that healthcare providers do no harm, and justice requires that
• resources be distributed fairly.
• In end-of-life care, ethical dilemmas often arise when patients can no longer make decisions
• for themselves. In these situations, healthcare providers must consider the patient's values and
• beliefs and the opinions of family members and other caregivers. It may be necessary to consult
• with a medical ethics committee or seek legal guidance to ensure that the patient's wishes are
• respected.
• One common ethical issue in end-of-life care is the use of life-sustaining treatments such as
• ventilators and feeding tubes. While these treatments can prolong life, they may also cause
• discomfort and suffering for the patient. In some cases, it may be appropriate to withhold or
• withdraw these treatments in order to provide the patient with a more comfortable and peaceful
• end-of-life experience.
• Overall, ethics-based decision making in end-of-life care requires careful consideration of
• the patient's values and beliefs and the ethical principles that guide healthcare practice. By
• balancing these factors, healthcare providers can ensure that end-of-life care is provided in a
• respectful, compassionate way, and in line with the patient's wishes.
• The foundation of medical ethics is supported by the four pillars, namely;
• 1. Autonomy- Patient has the right to choose or refuse a particular treatment. In the event the
• patient has diminished decision-making capacity, surrogates acting on the patient's behalf
• can communicate the patient's previously expressed wishes.
• 2. Beneficence- The doctor should act in the best interest of the patient. In the context of an
• advanced progressive illness with no scope for reversal, the patient's best interests are
• controlling the patient's pain and symptoms, reducing the sufferings of the patient and his
• family, providing emotional support and protecting the family from financial ruin.
• 3. Non-Maleficence- Do no harm to the patient. Thus, withholding and withdrawing the life
• support, in this context, is a humane approach to 'allowing natural death,' that is, allowing
• the patient to die of the underlying illness, with symptoms well–controlled, in a dignified
• manner, in the presence of his family and loved ones and this in no way amounts to
• euthanasia.
• 4. Justice- Equ
• Justice- Equitable distribution of service and equal right to care for all patients.
• Added to the above four are two more aspects which form the cornerstones of medical
• practice:
• 1. Dignity - the patient and the persons treating the patient have the right to dignity
• 2. Truthfulness and honesty - the concept of informed consent and truth-telling should be
• engrained in the practice of end-of-life care.
• Thus, it is crucial to integrate the ethical principles in the practice of palliative care and endof-
• life care in the background of cultural and social influence. End-of-life care must be
• embedded in the ethical principles of palliative care.
• Palliative care is important in advanced health-related suffering and life-limiting illnesses. The
• different aspects of palliative care, such as pain and symptom control, psychosocial care, and endof-
• life issues, should be managed ethically. The cardinal ethical principles to be followed are
• autonomy, beneficence, non-maleficence and justice.
• • The palliative care experts and team members should carry out their responsibilities with
• honesty and dignity.
• • Suffering due to unrelieved pain and unavailability of Morphine are recognized as negligence
• of human rights.
• • There are practical ethical challenges which need to be resolved. Truth-telling, place of care,
• continuity of effective palliative care till the last days of life, confidentiality, use of antibiotics
• and blood transfusion, nutrition and advance directives can be the key points which confront
• a palliative care team
• Progress in palliative care will come out of good research and medical professionals should
• undertake trials and studies in a legal and ethical manner.
• • The delivery of palliative care and medical ethics are complementary, and use of the two
• together maximizes the protection and satisfaction available to the vulnerable patient and
• family members.
• • Decisions are made on the grounds of benefits/burdens proportionality. To justify a particular
• intervention, the expected benefits of that intervention must outweigh the burdens. Burdens
• might include intractable pain, disability, emotional suffering or other factors which seriously
• compromise the patient's quality of life. Treatments considered reasonable in the early stages
• of illness when the patient is enjoying a good quality of life may be seen as unreasonable later
• in the illness. Furthermore, each intervention should be individually subjected to this
• consideration. For example, a patient who is not expected to benefit from ventilation may be
• helped symptomatically by administering oxygen. Importantly, the withholding or withdrawal
• of life-sustaining interventions should never mean the withdrawal of care. Adequate symptom
• control and emotional and spiritual support for the patient and family must be ensured.
• Collective decision making
• Dying is a very special and unique event for each individual. In palliative care approach
• exploring the patient's wishes about death and dying should be done in the beginning itself.
• Relatives need to be involved and patient’s wishes would need to be balanced with the palliative
• care team's views. Most patients wanted to be at home during the lost weeks or days around the
• relatives. Relatives should determine who and how the body is dealt with after death. This is an
• important part of their last 'duty’. It is important to be sensitive to the cultural and religious
• beliefs because different religious and cultural groups have different approaches the dying
• processes.
• Role of palliative care nurse
• • Coordinate with the other health care members and facilitate a death that's as dignified and
• comfortable as much as possible and that honours the patient's and family's wishes.
• Provide a culturally sensitive, practical, and timely interventions that reduce physical,
• emotional, and spiritual suffering.
• • Provide ongoing education to the patient and family members, who may have had little
• experience with death and may not understand the dying process.
• • Provide information about the patient's condition, discuss the risks and benefits of medical
• treatments, and answer family members' questions about care options for their loved one.
• • Guide the discussion and address the questions but do not dictate what decisions the patient
• and family should make.
• • Nurses must understand that the death approaches, the patient's comfort and the patient's and
• family's emotional and spiritual well-being and take precedence over clinical priorities.
• • Provide reassurance and physical presence are critical at this time to ease the patient's and
• family's fear and loneliness and to facilitate the transition.
• • Discuss patient preferences about withholding hydration and nutrition, the timing for
• discontinuing treatments, and the selection of a surrogate decision maker.
• • Adjust the temperature and lighting in the room, as needed
• • Observe for signs of terminal delirium, such as a decreased level of consciousness or
• unresponsiveness, confusion, disorientation, hallucinations, agitation, or restlessness.
• • Note that agitation is common in the final hours of life and may be due to the effects of
• medications, changes in metabolic status, organ failure, faecal impaction, bladder distention,
• hypoxia, and unresolved emotional or spiritual issues.
• • If the patient is experiencing agitated delirium, collaborate with the interdisciplinary team to

• identify and treat reversible causes if possible, such as discontinuing

unnecessary
• medications.
• Administer Haloperidol or another antipsychotic agent as prescribed following safe
• medication administration practices.
• • Treat the patient’s pain using non-pharmacologic, pharmacologic, or a combination of
• approaches.
• • Don't abruptly discontinue opioid pain medication, even if the patient is unresponsive.
• • Although a hypoxemic patient may benefit from supplemental oxygen, it isn't routinely used
• for air hunger at the end of life.
• • If the patient can't clear secretions, reposition the patient and elevate the patient's upper body
• and head. Administer an anticholinergic or antispasmodic, as appropriate and as needed and
• prescribed, following safe medication administration practices to dry secretions.
• • Note that sounds made by the patient with excessive secretions are often more distressing to
• family members than to the patient.
• • If the patient is experiencing nausea, collaborate with the interdisciplinary team to identify
• and treat reversible causes if possible. Administer anti-emetics, as needed and prescribed,
• following safe medication administration practices. Provide non-pharmacologic
• interventions, such as limiting movement and removing noxious odors, as appropriate.
• • Assess the patient for the effects of dehydration, such fatigue, dizziness, headache, dry
• mouth or eyes, scant or dark-colored urine, and muscle cramps,
• • Offer (but don't force) oral fluids if the patient can still swallow. Administer artificial
• hydration if ordered and consistent with the patient’s care goals. Advise the patient and

• family that administering fluids via the enteral or parenteral route doesn't reverse the
• underlying disease process or significantly increase survival and may contribute to the
• Administer Haloperidol or another antipsychotic agent as prescribed following safe
• medication administration practices.
• • Treat the patient’s pain using non-pharmacologic, pharmacologic, or a combination of
• approaches.
• • Don't abruptly discontinue opioid pain medication, even if the patient is unresponsive.
• • Although a hypoxemic patient may benefit from supplemental oxygen, it isn't routinely used
• for air hunger at the end of life.
• • If the patient can't clear secretions, reposition the patient and elevate the patient's upper body
• and head. Administer an anticholinergic or antispasmodic, as appropriate and as needed and
• prescribed, following safe medication administration practices to dry secretions.
• • Note that sounds made by the patient with excessive secretions are often more distressing to
• family members than to the patient.
• • If the patient is experiencing nausea, collaborate with the interdisciplinary team to identify
• and treat reversible causes if possible. Administer anti-emetics, as needed and prescribed,
• following safe medication administration practices. Provide non-pharmacologic
• interventions, such as limiting movement and removing noxious odors, as appropriate.
• • Assess the patient for the effects of dehydration, such fatigue, dizziness, headache, dry
• mouth or eyes, scant or dark-colored urine, and muscle cramps,
• • Offer (but don't force) oral fluids if the patient can still swallow. Administer artificial
• hydration if ordered and consistent with the patient’s care goals. Advise the patient and
• family that administering fluids via the enteral or parenteral route doesn't reverse the
• underlying disease process or significantly increase survival and may contribute to the
• physiologic burden of dying.
• • Although increasing oral intake is the preferred method of providing fluids, especially in the
• home environment, artificial hydration via the IV, subcutaneous (hypodermoclysis), or rectal
• (proctoclysis) route may be considered in some patients if the potential benefits, such as
• increased alertness and reduced myoclonus, outweigh the potential risks related to fluid
• retention, such as edema, nausea, pain, and dyspnea.
• • Provide oral care, taking care to moisturize the patient's oral mucosa and lips as needed, to
• prevent or relieve discomfort.
• • Lubricate the patient's eyes with an ophthalmic solution (such as artificial tears) or ointment,
• as needed and ordered, to prevent or relieve discomfort.
• • Assess the patient's skin for temperature, moisture, color, and breakdown. Note that as
• peripheral circulation decreases and death approaches, the skin is typically cool and moist
• and becomes mottled, especially on the soles of the feet and over bony prominences. Skin
• darkens in dependent areas, such as the sacrum (when the patient is supine), as blood pools
• in these areas.
• • Reposition the patient as tolerated, change the patient's clothing and linens when soiled or
• moist, and provide skin and wound care as indicated. (See the "Wound palliative care, home
• care" procedure.) Make sure that the linens cover the patient loosely to reduce discomfort
• caused by pressure from the linen.
• • Assess the patient for urinary and bowel incontinence, which can occur as the patient's
• sphincters relax as death approaches.
• • Change fluid-impermeable pads and provide perineal care, as needed. If the patient is
• incontinent of urine and can't tolerate repositioning and perineal care, insert an indwelling
• urinary catheter (if ordered) to promote comfort.
• Encourage family members to participate in the patient's care and teach them how to provide
• comfort measures to the patient, such as positioning, mouth care, skin care, and gentle
• massage.
• • Teach the patient and family members to use non-pharmacologic strategies, such as
• relaxation techniques, guided imagery, and distraction, to ease symptoms (such as
• discomfort, nausea, anxiety, depression, and fatigue) that may be present at the end of life. If
• the patient and family are interested in using complementary therapies (such as music
• therapy, massage therapy, and aromatherapy) to control symptoms, notify the patient’s
• practitioner for appropriate orders and referrals.
• • Reassess and respond to the patient’s pain by evaluating the response to treatment and
• progress toward pain management goals. Assess for adverse reactions and risk factors for
• adverse events that may result from treatment.
• • Provide the family with anticipatory guidance on the signs of impending death.
• • Support the patient and family in expressing cultural, spiritual, or religious traditions related
• to the end of life. Encourage the family to provide objects that comfort the patient, such as
• religious items or photographs.
• • Allow the patient and family to express their feelings, which may include acceptance,
• anxiety, denial, disappointment, loneliness, regret, resentment, and sadness. Actively listen
• without rushing them, and display empathy. Acknowledge their feelings and provide
• emotional support.
• Encourage the patient and family to reminisce and appropriately
express affection. Remain
• present or provide privacy according to their wishes
• • Ask the patient and family about organ and tissue donation when
appropriate. Explain the
• process or, if the patient has already registered to become a donor,
verify the registration in
• the patient's medical record. Contact a regional organ procurement
organization for specific
• organ and tissue donation criteria.
• • Review progress toward the goals in the patient’s plan of care with the
patient and family as
• appropriate.
• • Make arrangements for the next visit as appropriate and ensure the patient
and family
• members have adequate supplies for caring for the patient themselves until
then.
• • Provide and review written educational materials, the visit schedule, and
contact information
• should concerns arise between visits