GRIEF AND LOSS

Loss Death and Dying (Kozier)

- It is a universal experience that occurs
throughout the lifespan. AGE BELIEFS
- Something of value is gone.
Infancy to 5 No clear concept of death
y/o It is reversible, temporary sleep
Grief
- It is a form of sorrow involving feelings, Understands death is final but
5 - 9 y/o
thoughts and behaviors caused by can be avoided
bereavement. Death is inevitable
- Total response to emotional experience related 9 - 12 y/o
Understand own mortality
to loss.
12 - 18 y/o Fears a lingering death
Responses to loss are strongly influenced by one’s
cultural background. 18 - 45 y/o Attitude is influenced by religion

The grief process involves a sequence of affective,

cognitive and psychological states as a person 45 - 65 y/o Experience peak of death anxiety
responds to and finally accepts a loss.
65 ↑ Death is multiple meanings
Bereavement
- Subjective response to by loved ones.
Death
Mourning - end of life
- behavioral response - full cessation of vital actions
- Permanent state in the field of biology
- all living things eventually die
Stages of Grieving (Kubbler-Ross)
Attitudes about Death and Dying
Denial refuses to believe - Present generation may be unaware of feelings
- Prolonging life
the individual resists the loss and - Common fears
Anger - Behaviors of health care professionals
may “act out” feelings.
the individual attempts to make a
Bargaining deal in an attempt to postpone the
reality of loss. DENIAL
- “No, not me…”
overwhelming feeling of loneliness
Depression Intervention
and withdrawal from others.
o do not interfere unless it becomes
the individual comes to terms with destructive
loss, or impending loss, o do not support denial; conversations
Acceptance psychological reactions to loss to should include reality
the loss cease, and the interaction o continue to teach and encourage self-care
to other people resumed. activities

ANGER
- “why me?”
- expression of emotion

1

Intervention
o give space allowing them to rail and below,
the more the storm blows the sooner it will
blow itself out
o try not to respond in “kind”
o when anger is destructive, it must be
addressed directly. Remind the person of
appropriate and inappropriate behavior.
BARGAINING
- “yes me, but…”
- attempts to negotiate
Intervention
o spend time with patients
o discuss importance of valued objects and
people.
DEPRESSION
- the inevitability of the news eventually (and not
before time) sinks in and the person reluctantly
accepts that it is going to happen.
Intervention
o be available
o don’t attempt to cheer person up
o find out any religious support
- Increase in chest fluids
- Grunting and moaning on expiration
- Skin changes
Nursing Responsibilities in Death and Dying
- Nurses need to take time to analyze their own
feelings about death before they can effectively
help others with terminal illness
- The major goals for the dying clients are:
» to maintain PHYSIOLOGIC and
PYCHOLOGIC support
» to achieve a dignified and peaceful death
» to maintain personal control
Loss and Death RESPONSIBILITIES
- Provide relief from loneliness, fear and
depression
- Help clients maintain sense of security
- Help clients accept losses
- Provide physical comfort

ACCEPTANCE
- restful time, but not necessarily happy
- often begin putting their life in order, sorting
out wills and helping others to accept the
inevitability
Intervention
o plan care to allow the person with whom
patient is comfortable to care for him or her
o it is important that you don’t withdraw

Signs and Symptoms of Approaching Death

- May have increased hallucinations
- Decreased appetite
- May have temperature spikes
- Incontinent for stool and urine 24 to 72 hours
prior to death
- Pain may be more intense
- Restlessness is common 12 to 24 hours prior
to death
- Changes in respiratory status

2
 - Nursing staff must treat the dying person
without fear, encourage relatives to be close to
him, act as a liaison with the outside world

In the Intellectual Level

- The new reality: irrational, unfair, difficult
- “why”
- Need to evaluate his life as meaningful,
TAKING CARE OF THE DYING PERSON important, useful
- The role of the nursing staff is fundamentally - Nursing staff should stand by him without being
supportive judgmental, let him decide where he wants to
- Accept the physical and mental state he is in spend his last days, and interact with him as a
- Show him that they will not abandon him person who LIVES
- Responds to the persons need in a physical,
psychological, social and intellectual level Nursing Responsibilities
- Nurses need to take time to analyze their own
In the Physical Level feelings about death before they can effectively
- Biological needs, reduction and control of pain help others with terminal illness
- Pain is a subjective experience - Understand that you may experience grief
- Acute pain: usually temporary - Nurses have to be strong to control their
- Chronic pain: interrupts normal everyday feelings to be able to tolerate pain, illness, and
functioning death, and to keep their distance
- Medication is more effective in the context of a - Provide relief from illness, fear and depression
holistic intervention - Help clients maintain sense of security
- Help accept losses
In the Psychological Level - Provide physical comfort
- Feelings of anger, sadness, depression are part
of a wider process of “anticipatory grief”, DEATH CONCEPTS
preparation to die
immobility and inactivity; wishes
- Nursing staff has to comprehend and the
1–5 y/o and unrelated action responsible
person to express these feelings
for action
- The only way for the person to reconcile with
these feelings is to talk to someone willing to 5-10 y/o final but can be avoided
listen
- Support has to respond to the person’s need for understands own mortality and
9–12 y/o
safety, autonomy and self-control fears death
12–18
In the Social Level fears and fantasizes avoidance
y/o
- Emotional and social withdrawal
18–45
- Need of emotional withdrawal co-exists with increased attitude awareness
y/o
the need of belonging to an accepting and
supportive social environment 45–65
accepts mortality
- When family/medical nursing staff keep their y/o
distance in order to protect themselves, the multiple meanings; encounters and
person experiences a “social death”, which is above 65
fears
sometimes more painful than the actual death
Interventions
D- Supportive

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A- Provide structure and continuity
B- Listen and encourage
D- Allow expression and provide safety
A- Encourage participation
ASSISTED SUICIDE
Death with Dignity or Murder?
What is Assisted Suicide?
- General term for helping a patient to terminate
their life
- Majority of assisted suicide are requests from
severely or terminally ill patients
Euthanasia
- The word Euthanasia originated from the Greek
language: eu means “good” and Thanatos
means “death”
- Another word for euthanasia is mercy killing
- Euthanasia literally means ‘good death’ and
generally aims to hasten the death of people
who suffer severely without any hope of
recovery.
Voluntary Euthanasia
- when the person who is killed has requested to
be killed
Non-voluntary Euthanasia
- when the person who is killed made no request
and gave no consent
- The act of euthanasia today is understood as
termination of life on request
- But it has not always been people’s choice
- The voluntary decision to terminate life has
been misused during the human history,
especially between 1933 and 1945 during the
German Nazi regime in Europe.
- This criminal regime murdered millions of
people because they were disabled, ill, old or of
different ethnic group.
- Murders committed for these reasons were also
called “euthanasia”
4
- Nazi regime excused their criminal deeds as
termination of “worthless lives”
- This is against the humane nature of love and
compassion, and equal human rights.
Assisted Suicide
- someone provides an individual with the
information, guidance, and means to take his
or her own life with the intention that they will
be used for this purpose.
Physician Assisted Suicide
- when it is a doctor who helps another person to
kill themselves
Euthanasia by Action
- intentionally causing a person’s death by
performing an action such as giving a lethal
injection.
Euthanasia by Omission
- intentionally causing death by not providing
necessary and ordinary (usual and customary)
care or food and water
- The crimes committed in the past are one of the
reasons why termination of life on request is a
criminal act in almost all States of the world.
- In the Netherlands voluntary euthanasia has
been decriminalized.
- This made the Netherlands the first country in
the world to formally sanction mercy killing.
(Belgium, Oregon)
- Under the new law, euthanasia is administered
only to patients who are in a state of
continuous, unbearable and incurable
suffering.
- These are other requirements as well:
o A second opinion from an external
physician
o The patient must be judged to be sound of
mind
o A request to die must be made voluntarily,
independently and persistently.
THESE ARE NOT EUTHANASIA
1. Not commencing treatment that would not
provide a benefit to the patient.
2. Withdrawing treatment that has been shown to
be ineffective, too burdensome or is unwanted.
3. The giving of high doses of pain-killers that may
endanger life, when they have been shown to
be necessary.
TYPES OF ASSISTED SUICIDE
1. Euthanasia
- Physician prescribes the treatment
- Physician directly administers the
treatment to the patient
2. Physician-Assisted Suicide
- Physician prescribes the treatment
- Patient administers the treatment
- Physician does not administer the
treatment
TYPES OF EUTHANASIA
1. Active
- Administering treatment to end life
2. Passive
- Withholding from treatment to end life
3. Voluntary
- Patient consents to treatment
4. Involuntary
- Patient is unable to consent to treatment
LEGALITY
- Euthanasia
» Illegal in the United States, Canada
» Legal in Netherlands, Belgium
- Physician-Assisted Suicide
» Legal in Oregon, Washington, Montana
» Legal in Netherlands
OREGON’S DEATH WITH DIGNITY ACT
1. Requires the patient give a fully informed,
voluntary decision.
2. Applies to the last 6 months of the patient’s
life.
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3. Makes it mandatory that a second opinion by a
qualified physician be given that the patient
has fewer than 6 months to live.
4. Requires two oral requests by the patient.
5. Requires a written request by the patient.
6. Allows cancellation of the request at any time.
7. Makes it mandatory that a 15-day waiting
period occurs after the first oral request.
8. Makes it mandatory that 48-hours (2 days)
elapse after the patient makes a written
request to receive the medication.
9. Punishes anyone who uses coercion on a
patient to use the Act.
10. Provides for psychological counseling if either
of the patient’s physicians thinks the patient
needs counseling.
11. Recommends the patient inform his/her next of
kin.
12. Excludes nonresidents of Oregon from taking
part.
13. Mandates participating physicians are licensed
in Oregon.
14. Mandates Health Division Review.
15. Does not authorize mercy killing or active
euthanasia.
CONTROVERSY
- Against
» A cry for help
» Suicide intent is not permanent
» Depressed
» Financial obligation to families
» Pain is controllable
» Legalizing physician-assisted suicide
would legalize euthanasia
» Murder
» Sin
- For
» Not all pain or situations are controllable
» There are safeguards
» Humane
» Patient self-determination
IMPACT
- Patients
» In 47 states terminally ill patients cannot
choose to end their suffering
 » In the 3 states that have legalized
physician assisted suicide, terminally ill
patients are faced with a monumental
decision
- Healthcare and Human Service Workers
» Many healthcare and human service
workers would be and have to be involved
in physician-assisted suicide cases against
their beliefs.
Quality end-of-life care requires:
- Appropriate control of pain and symptoms
- Avoid inappropriate prolongation of dying
- Enhance the control of patients over their care
- Rest with family
- Supported by physicians, nurses, and social
workers
PALLIATIVE CARE
Introduction
- Palliative care is developing as an areas of
special clinical competence throughout the
world. The modern hospice is a relatively recent
concept that originated and gained momentum
in the United kingdom after the founding of St.
Christopher‘s hospice in 1967. It was founded
by Dame Cicely Saunders, widely regarded as
the founder of modern hospice movement.
- Palliative medicine has been recognized as a
specialty in UK since 1987, in Australia and
New Zealand since 1988 and more recently in
Canada.
Definition of Palliative Care
- Palliative care is an approach that improves the
quality of life of patients and their families
facing the problem associated with life-
threatening illness, through the prevention and
relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual. - WHO 2002
- ‘to mitigate the sufferings of the patient, not to
effect a cure’ (Macpherson, 2002)
- Palliative care aims to relieve symptoms and
improve the quality of living and dying for a
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person and/or family living with a life
threatening illness.
- Palliative care strives to help individuals and
their families:
» address physical, psychological, social,
spiritual and practical issues and
associated expectations, needs, hopes and
fears,
» prepare for, and manage, life closure and
the dying process, and
» cope with loss and grief during the illness
and bereavement.
- The National Council for Palliative Care, which
is an umbrella organization for setting
standards in specialist palliative care in the UK,
published its current definition in 2002 NCPC
definition of palliative care.
- Palliative Care
» Affirms life and dying as a normal process;
» Provides relief from pain and other
symptoms;
» Integrates the psychological and spiritual
aspects of patient care;
» Offers a support system to help patients
live as actively as possible until death;
» Offers a support system to help the family
cope during the patient‘s illness and in
their own environment.
» Source: National Council for Palliative Care
(2002)
1. Palliative Care may:
» complement and enhance treatment of the
disease at any time during the disease
trajectory, or become the total focus of
care.
» Palliative care may be provided to
individuals:
 with any diagnosis
 regardless of age, and
 when they have unmet needs and are
prepared to accept care.
Terminologies
1. Autonomy
 - “the state of being self- governed” (CPCA, Parkin, D.M., Bray, F.I., and Devesa, S.S. (2001).
2001). Cancer burden in the year 2000. The global picture.
- Thinking and acting independently without European Journal of Cancer 37, 4–66
outside influence and direction.
2. Bereavement
- “the state of having suffered the death of ESTIMATION
someone significant” (CPCA,2001) - One million cases of cancer occur each year in
3. Caregiver India, with over 80% presenting at stage III and
- “anyone who provides care” IV. Two thirds of patients with cancer are
- Care givers are people who are willing to incurable need palliative care and
listen to ill persons and responds to their approximately one million people are
individual experiences (Twycross R 2003). experiencing cancer pain every year.
- Formal caregivers are members of an - According to WHO, more than four million
organization and accountable to defined cancer patients would benefit from palliative
norms of conduct and practice. They may care. Less than one percent of those who need
be professionals, support workers, or palliative care services have access to such
volunteers. services in India.
- Informal caregivers are not members of an
organization. They [usually] do not have
formal training, and are not accountable to NEED OF PALLIATIVE CARE
norms of conduct or practice. They may be - Size of problem. Estimated number of people
family members or friends. (CPCA, 2001) who would need palliative care (in millions)
4. Dignity - Annual deaths globally: 56
- To treat individuals with respect, esteem - Annual deaths in developing countries: 44
and regard - Annual deaths in developed countries: 12
5. Family - Estimated numbers needing palliative care: 33
- Whomever the person says is his or her - It can be estimated that approximately 60% of
family. The family may include relatives, the dying need
partners, friends and pets. - Since death also affects family members and
6. Grief close companions, perhaps one to two persons
- Reactions (physical, emotional, behavioral, giving care and support for everyone who dies,
spiritual) experienced in anticipation of, then a conservative figure might be 100 million
during and after a loss. people who would benefit from the availability
7. Needs of basic palliative care.
- Issues that patients and caregivers
mutually agree require attention in the plan
of care. Milestones in Palliative Care in India
- 1986 - First hospice care - “Shanti Avedana
Ashram” – at Mumbai.
NEED OF PALLIATIVE CARE - 1990 - Cancer Relief India (CRI) a UK charity
- Cancer Burden: global picture founded - provide education to doctors and
- Number of new cancer cases (in millions) nurses in palliative care and providing pain and
2000 2020 2050 symptom relief for cancer patients.
World 10.6 15.3 23.8 - 1994 – Pain and palliative clinic at Calicut.
Developing Countries 5.4 9.3 17.0 - 1994 - Indian association of Palliative care
Developed Countries 4.6 6.0 6.8 with WHO and Govt of India - aim is to
propagating palliative care in India along with

7
 facilitating education initiatives and drug
availability.
- 1993-95 - CRI and Cancer Relief Macmillan
Fund with WHO facilitated training of doctors
and nurses in palliative care.
- 1997 - Can support, Delhi. (first palliative care
home in north India)
- 1999 - first nurse from India sponsored by CRI
to complete the diploma in palliative nursing at
Oxford Brookes University.
- 2001 - Neighborhood Netwrok in Palliative care
(NNPC) has a network of 150 such clinic
supported by 10,000 trained volunteers, 85
doctors and 270 nurses looking after about
25,000 patients at any point.
- 2001 - Guwahati Pain and palliative care
Society.
- 2008 - first palliative care policy in Kerala. The
policy emphasis the community based
approach to palliative care and considers home
based care as the corner stone of the palliative
care services.
- Psycho oncology in India - integrated services
linking training, clinical services and research
activities which are linked at several levels
involving volunteers in the community.
- The word ‘palliative’ has its origins in the Latin
word ‘pallium’ meaning to cloak or cover. In the
context of how cancer was perceived and poorly
diagnosed from the middle ages until perhaps
the latter half of the 20th century, it is an
appropriate description. Even today, there are
many cancers that grow unseen and without
symptoms for a considerable time before the
person seeks help.
- The term “palliative care" is increasingly used
with regard to diseases other than cancer such
as chronic, progressive pulmonary disorders,
renal disease, chronic heart failure, HIV/AIDS,
and progressive neurological conditions.
- Palliative care (pronounced pal-lee-uh- tiv) is
specialized medical care for people with
serious illnesses. It focuses on providing
patients with relief from the symptoms, pain,
and stress of a serious illness—whatever the
8
diagnosis. The goal is to improve quality of life
for both the patient and the family.
Philosophy of Palliative Care
- To give people with life limiting illnesses a
reason to hope and a feeling of greater self-
confidence and dignity.
- We embrace a holistic approach to care giving,
which respects the dignity and worth of each
person.
- We believe in creating an environment that
nurtures the physical, intellectual, social and
spiritual wellbeing of those in our care.
- Palliative, or comfort care, recognizes that
death is a normal part of life and strives to
prepare patients and their families so we can
all die on our own terms.
- From the start of a serious or terminal illness,
practitioners reduce the burden on family
caregivers by identifying and providing for the
needs of you and your family.
- These needs may be physical, emotional, social
or spiritual.
The Canadian Palliative Care Association (2001)
Proposed Norms of Practice for Hospice Palliative
Care
We believe:
- Access is Foundational
» Palliative care services should be available
to all who require care.
- Care is Patient-Focused
» Palliative cares strives to meet the
physical, psychological, spiritual and social
needs of patients and families.
» It is sensitive to personal, cultural and
religious values, beliefs and practices,
developmental state, and readiness to deal
with the dying process
- People Have the Right to Choice
» Each person is an autonomous and unique
individual with the right to participate in
informed discussion related to care and to
 choose the best possible options and
outcomes based on that information.
- Dying is Part of Life
» Palliative care affirms life. Euthanasia and
physician assisted suicide are not
considered options. Palliative care never
intentionally hastens death.
- Quality of Life Guides Decisions
» Care choices should be guided by quality of
life as defined by the patient.
- Team Work Is Essential
» Palliative care is a network of services most
effectively delivered by an interdisciplinary
team who rely on shared knowledge,
expertise and effective interactions.
- Service is Coordinated
» A palliative care program should promote
continuity of care across settings and
coordination amongst all involved
caregivers and programs/services.
- Accountability is demonstrated through
Outcomes
» We are accountable to ourselves, each
other, to our individual sites, to the
regional program and to the public we
serve. Accountability is demonstrated
through measurable goals.
- Confidentiality is Central
» Patient information is treated with the
utmost respect. Team members must
adhere to this principle.
- Care Setting Is Important
» Palliative care is provided in a patient and
family focused environment in the most
appropriate care setting such as the home,
hospice, continuing care centers, acute
hospitals or on a tertiary palliative care
unit. The needs and preferences of the
patient and family, as well as the resources
available, are taken into consideration.
- Caregiver Well-Being Is Fundamental
9
» The provision of ongoing support to
enhance formal and informal caregivers’
well-being is integral to a successful
palliative care program.
- On-going Education is Essential
» Patient, family, caregiver and public
education is important to the maintenance
and enhancement of the quality of
palliative care.
- Research Leads to Advancement in Care
» The development, dissemination and
integration of research are critical to
palliative care.
- Resources Influence Program Quality
» Adequate resources, responsibly managed,
are imperative to maintain and advance
palliative care programming.
- Collaborative Leadership is Advantageous
» The development and maintenance
SCOPE
- Palliative care is the specialized medical care
for people with serious illness.
- provides relief from pain, shortness of breath,
nausea and other distressing symptoms;
- affirms life and regards dying as a normal
process;
- intends neither to hasten nor to postpone
death;
- integrates the psychological and spiritual
aspects of patient care
- offers a support system to help patients live as
actively as possible;
- offers a support system to help the family cope;
- uses a team approach to address the needs of
patients and their families;
- will enhance quality of life;
- 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.
MAIN AIMS
Improve the Avoid the avoidable
Quality of Life
Wellbeing
suffering
Promote Comprehensive
Comfort Care
AIMS AND PRINCIPLES OF PALLIATIVE CARE
- Respect the likes and dislikes, goals choices of
the dying person.
- Integrates the psychological and spiritual
aspects of patient care.
- Offers a support system to help patients live as
actively as possible until death.
- Patient centered rather than disease focused.
- Concerned with healing rather than curing.
- Affirms life & regards dying as normal process
i.e as a part of the life cycle.
- Builds ways to provide excellent care at the end
of the life. Through education of care providers,
appropriate health policies
Building and adequate
Capacity:
empowerment to adjust
funding from insurers
relief andand the
support the government.
- Provides relief from pain and other distressing
unavoidable suffering
symptoms.
- Death accepting but also life enhancing.
- Intends neither to hasten nor post pone death.
- Adds life to days and not days to life.
- Partnership between the patient and the care
providers.
- Supports the need of the family members
- Helps then in gaining access to needed health
care providers & appropriate care settings.
Involving various kinds of trained providers in
different setting tailored to the needs of the
patient and his or her family
- Offers support system to help the family to cope
during the patient’s illness and in their own
bereavement, including the needs of children.
- Uses a team approach to address the needs of
patients and their families including
bereavement, counseling, if indicated.
- Enhance the quality of life, may also positively
influence the course of a patients illness.
10
- Palliative care for children is the active total
care of the child's body, mind and spirit, and
also involves giving support to the family.
- It begins when illness is diagnosed, and
continues regardless of whether or not a child
receives treatment directed at the disease.
- Health providers must evaluate and alleviate a
child's physical, psychological, and social
Symptom Psychologica
distress.
Relief Hope l
- Support
Effective palliative care requires a broad
Honesty
multidisciplinary approach that includes the
family and makes Openness
use of available community
resources; it can be successfully implemented
Teamwork
even if resources areand Partnership
limited.
- It can be provided in tertiary care facilities, in
community health centers and even in
children's homes.
- Palliative care is provided by a team of doctors,
nurses and other specialists who work together
with a patient‘s other doctors to provide an
extra layer of support. It is appropriate at any
age and at any stage in a serious illness and
can be provided along with curative treatment.
- The core team includes doctor, nurse and social
work palliative care specialists. Massage
therapists, pharmacists, nutritionists,
chaplains and others may also be part of the
team.
GOALS OF PALLIATIVE CARE
- Achievement of the best possible quality of life
for patients and their families regardless of the
stage of the disease or the need for other
therapies
- Three essential component of palliative care:
- Palliative care is still sometimes defined as
solely being for people with cancer, but
palliative care is more often now defined as
 being for people facing a life- threatening helps you have more control over your care by
illness. Palliative care is not usually defined as improving communication so that you can
being for people with chronic diseases such as
Cure/Life- better understand your choices for treatment.
Prolonging Intent
diabetes.
Death Bereavement
Palliative/Comfort
Intent A PALLIATIVE APPROACH
PALLIATIVE CARE MODEL
Aims:
- to improve the quality of life for individuals with
a life-limiting illness and their families, by
reducing their suffering through early
identification, assessment and treatment of
pain, physical, cultural, psychological, social
and spiritual needs

MYTHS ABOUT PALLIATIVE CARE

- Residents will become addicted to pain relief
drugs.
- The palliative approach is only provided in
hospital type settings
- You need to be an expert to be able to provide
EVOLVING MODEL OF PALLIATIVE CARE the care
- You need to be a nurse to be able to provide the
care
Diagnosi Advance
s d - Applying the palliative approach will increase
Disease the care worker‘s work load
- The palliative approach is only provided to
residents with cancer
- The palliative approach costs more.
Palliative
Treatment
Care

Time Course of Illness

PC TEAM

Potential members of the interdisciplinary team for

D a palliative approach may include but not be
PALLIATIVE E limited to:
ACTIVE TREATMENT A
CARE - Care assistants
T
H - General Practitioners
- Palliative care focuses on symptoms such as - Generalist nurses
Cure/Life Prolonging D
pain, shortness of breath, fatigue,
Intent
constipation, - Specialist nurses
E
nausea, loss of appetite, difficulty
A sleeping and - Aboriginal health workers
Palliative/
depression. ItComfort
also helps T
Intent you gain the strength - Trained volunteers and their coordinators
H
to carry on with daily life. It improves your - Pharmacists
ability to tolerate medical treatments. And it - Chaplains/pastoral care workers

11
Recreation activity officers ELEMENTS OF PALLIATIVE CARE
- Pain specialists
- Allied health practitioners 1. PRIMARY GOAL
- Specialist physicians The primary goal is to prevent and relieve
- Community/ palliative services sufferings imposed by disease and their
- Psychologists/ psychiatrists treatment, achievement of best possible quality
- Specialist palliative service providers of life for patients and their families regardless
- Managers of the stage of the disease or need for other
- Home attendants • therapies.
- Physical, occupational, art, play, music
therapist. 2. PATIENT POPULATION
- Bereavement coordinators Patients of all ages experiencing a debilitating
chronic or life threatening illness, condition or
injury.
SERVICES PROVIDED BY PALLIATIVE CARE
- Interdisciplinary team care- nursing services, 3. PATIENT AND FAMILY CENTERED CARE
medical, social, pastoral counseling, home The uniqueness of each patient and family is
health aide. respected. The patient family constitute the
- Bereavement counseling unit of care.
- Dietary counseling
- Physical therapy 4. TIMING OF PALLIATIVE CARE
- Occupational therapy It ideally begins at the time of diagnosis of a
- Speech therapy life threatening or debilitating condition and
- Investigations and drugs continues through cure, or until death and into
- Durable medical equipment and supplies the family‘s bereavement period.

PALLIATIVE CARE PATIENT SUPPORT SERVICES
Three Categories of Support:
1. Pain Management
- is vital for comfort and to reduce patients‘
distress. Health care professionals and
families can collaborate to identify the
sources of pain and relieve them with drugs
and other forms of therapy.
2. Symptom Management
- involves treating symptoms other than pain
such as nausea, weakness, bowel and
bladder problems, mental confusion,
fatigue, and difficulty breathing
3. Emotional and Spiritual Support
- is important for both the patient and family
in dealing with the emotional demands of
critical illness.
5. COMPREHENSIVE CARE
Palliative care employs multidimensional
assessment to identify and relieve sufferings
through the prevention or alleviation of
physical, psychological, social and spiritual
distress.
6. INTERDISCIPLINARY TEAM
Team work is an integral part of the philosophy
of palliative care. Require the expertise of
various providers in order to adequately assess
and treat the complex needs of seriously ill
patients and their families.
7. COMMUNICATION SKILLS
Effective communication skills are requisite in
palliative care. These includes appropriate and
effective sharing of information, active
listening, determination of goals and
preferences, assistance with medical decision
making, and effective communication with all

12
 individuals involved in the care of patients and
their families.
8. SKILL IN CARE OF THE DYING AND BEREAVED
Team must be knowledgeable and skilled in
providing care for the dying and the bereaved.
9. CONTINUITY OF CARE ACROSS SETTINGS
Palliative care is integral to all health care
delivery system settings (hospital, emergency
dept, nursing homes, home care, assisted living
facilities, outpatient and non-traditional
environments such as schools. The palliative
care team collaborates with professional and
informal care givers in each of these settings.
10. EQUITABLE ACCESS
Palliative care teams should work toward
equitable access to palliative care across all
ages and patient populations, all diagnostic
categories, all health care settings including
rural communities, and regardless of race,
ethnicity, sexual preferences or ability to pay.
11. QUALITY IMPROVEMENT
Palliative care services are committed to the
pursuit of excellence and high quality of care
which enhances the quality of life.
BENEFITS OF PC
Palliative approach offers many benefits to the
residents, their families and the health care team.
Some of these are:
- reducing potential distress to residents and
their families caused by a transfer to an acute
care setting
- reducing the admission and/or transfer of
residents to acute care facilities as care staff
develop the skills to manage the palliative care
residents
- increasing the involvement of the resident and
their family in the decision making about their
care
- encouraging open and early discussion on
death and dying
- allowing for advance care planning
13
- providing opportunities, especially for
improved control of pain symptoms, in a setting
that is familiar to the resident
- offering the resident and family consistent and
continuous care
APPROACHES TO PALLIATIVE CARE
- Not a “one size fits all approach”
- Care is tailored to help the specific needs of the
patient
- Since palliative care is utilized to help with
various diseases, the care provided must fit the
symptoms
WHAT DOES PALLIATIVE CARE PROVIDE TO A
PATIENT?
- Helps patients gain the strength and peace of
mind to carry on with daily life
- Aid the ability to tolerate medical treatments
- Helps patients to better understand their
choices for care
PALLIATIVE CARE NURSING
PHYSICAL
SOCIAL SPIRITUAL
EMOTIONAL
- Reflects whole aspects care. It combines the
humanistic approach with a scientific
approach.
- Physical wellbeing: Free of pain and
discomfort, functional ability etc.,
- Psychological well being: free from
anxiety/fears, ability to experience happiness
etc.,
- Social well-being: Purposeful life role, free from
financial burden.
- Spiritual well-being: feelings of hope, meaning
to life.
PHYSICAL NEEDS
- Palliative care professionals provide highly
skilled management of pain and other
symptoms such as anxiety, constipation,
nausea, breathing difficulties and confusion.
- They also help patients and families cope with
common changes such as loss of appetite,
weakness, bowel and bladder problems, as
well as side effects of therapies.
- Most pain and other symptoms can be
managed at home or in hospice. Some
treatments may require diagnostic tests that
must be done in a hospital.
- A small percentage of patients will need to be
admitted to a tertiary palliative care unit for
severe and complex symptoms.
EMOTIONAL AND SPIRITUAL NEEDS
- The health of the whole person is important in
hospice palliative care. Hospice palliative care
recognizes emotional and spiritual distress as
important sources of suffering requiring
support in addition to physical symptoms.
- Care teams offer help with non-physical pain
through counseling and spiritual support to
manage the emotional, social and spiritual
impact
- We also offer a variety of bereavement and
counseling services to friends and family
members before and after a patient‘s death.
PALLIATIVE CARE COMPETENCIES / SKILLS
- Communication skills
- Physical skills
- Psychosocial skills
- Teamwork skills
- Intrapersonal skills
- Life closure skills
COMMUNICATION SKILLS
The ability
14
- To field and respond to sometimes profound or
rhetorical questions about life and death
- To know when to say nothing, because that is
the most appropriate response;
- To use therapeutic comforting touch with
confidence;
- To challenge colleagues who may wish to deny
patients information; and, perhaps
- To discuss the imminent death of a relative with
families
TEAMWORK SKILLS
- The growth of the nursing role within these
teams has been dramatic and continues to
represent a much admired model of working.
PHYSICAL CARE SKILLS
- The knowledge and skills necessary to deliver
active, hands-on care in whatever setting
throughout a long period of illness.
- Observational skills and the intuitive ability to
recognize signs
- Advising doctors of the appropriate
prescription and dosage to manage pain
- The advocacy role nurses have towards patients
at a time of extreme vulnerability.
PSYCHOSOCIAL SKILLS
An ability
- To work with families,
- Anticipating their needs,
- Putting them in touch with services and
- Supporting them when appropriate
INTRAPERSONAL SKILLS
- Nurses need to recognize and attempt to
understand personal reactions that occur as a
natural consequence of working with dying and
bereaved people and to be able to reflect on
how this affects care given in sensitive
situations.
- It is the most challenging of all competency
areas and plays a significant part in the
professional growth of those who choose to
work in this field.

LIFE CLOSURE SKILLS
- This area is concerned with nursing behaviors
and skills that are crucial to patients and
families; dignity, as they perceive it, when life is
close to an end and thereafter.
- Such care has been described as a sacred
work, in which the nurse enters into the
patient‘s intimate space and touches parts of
the body that are usually private
SKILLS NEED PALLIATIVE CARE NURSE
A COMMITTED PERSON
- A Nurse stays with the patient or visits the
patients many times during the course of the
patient’s illness. She may have to stay with her
patient for a long time if it makes the patient as
ease. She may have to become a person
oriented nurse in order to give holistic care.
A GOOD LISTENER
- Verbal expressions are always heard. Body
language tells many things. Activities like
sitting alone in an area of significance or using
articles of a particular person who passed away
tells us that area or the use of that specific
article gives him comfort and he is preparing
himself for leaving this world.
- Nurse allow them to ventilate their anxiety for
coping with the present situation.
A GOOD COMMUNICATOR
- A nurse needs to be honest with the patient
about the disease. She needs to answer in
simple ways so that the patient and the
relatives can understand.
- Your patient may need an extra minute or a
comforting word from you which makes a
difference. She needs to use right word, in right
to me and pitch with the right attitude for
reaching out to the patient effectively.
- Acute care nurse plays a pivotal role in clinician
- significant others, communication in the
acute are settings.
15
EMPATHETIC TO THE EMOTIONS (OF PATIENTS AND
RELATIVES)
- Patient and relatives may shout and scream at
you. They may blame God for pain and all
difficulties. Palliative care is seen as the end of
the road of care. Reacting to their anticipated
grief and crisis and helping them appropriately
makes to be at ease.
- Families and the patient needs to know the
truth as they may need to reorganize and adopt
their lives towards the attainment of more
achievable goals, realistic hopes and
aspirations. (Fallowfield L J et al 2002).
- Nurses role was a supportive one with multiple
dimensions. Model of the supportive role in
palliative care was developed , comprised of six
intervoven dimensions. Valuing, connecting,
empowering, doing for, finding meaning and
preserving own integrity.
ABLE TO UNDERSTAND THE PAIN
- ‘Pain is what the patient says hurts’ (Twycross R
2003). The intensity of pain increases or
decreases according to the mood of the
patient. It could be acute or chronic. Causes of
pain can be due to chemotherapy,
constipation, and radiation therapy, physical or
psychological problems. Pain management in
patient includes modifications of the
pathological process by giving radiation
therapy, chemotherapy or surgery.
- Along with opioids and non-opioids are also
used. Adjuvant includes corticosteroids,
antidepressants, antiepileptic us, muscle
relaxants antispasmodics and
bisphosphonates.
- Nurse teach the patient about non drug
methods include
› massage,
› application of heat pads,
› acupuncture,
› relaxation therapy, and
› behavioral therapy can be used to reduce
the pain.
ABLE TO RECOGNIZE ASSOCIATED
NEUROPSYCHIATRY CONDITIONS
- Cancer related fatigue, and sleep disturbances
must be considered as a clinical
syndrome.(Barton Buake 2006).
- Cancer patient with advance disease may
prone to delirium, depression, suicidal
ideation, and severe anxiety. People who
receives systematic cancer treatment were
some what impaired in executive function,
verbal memory and motor functioning (Nail
2006).one third of cancer population
experiences some variety of distress , only
about 10% receives any psychosocial therapy
(Vanchon M 2006).
ROLE OF NURSE IN PALLIATIVE CARE
CARING FOR THE PATIENT
1. Direct nursing care
2. Meeting physical needs & symptoms
management.
3. Providing psychological reassurances
4. Monitoring & administering pain relief
intervention, both pharmacological and non
pharmacological.
5. Preventing complications – preventing,
monitoring & relieving discomfort relaxation &
contentment & preventing complication.
6. Educating family in basic nursing care.
7. Facilitating participation of significant others in
patient care.
8. Specialized nursing care related to
- Lymph edema management
- wound care
- stoma care
- bowel and bladder care
PALLIATIVE CARE PLAN INCLUDES
› care goals
› symptom management
› advance care planning
› financial planning
› family support
› spiritual care
› functional status support and
rehabilitation
› co morbid disease management
16
USE THERAPEUTIC COMMINICATION
- Establish caring and trusting relationship
- Assess the stage, types of the grief, and its
signs and symptoms.
- provide reassurance and respect
- Invite the clients to reveal the emotions &
consensus of greatest importance to them.
- Avoid communication barrier
PROVIDE PSYCHOSOCIAL CARE
- They may have anxiety, depression, altered
body image, powerlessness, uncertainty and
isolation.
- Provide information that help the client to
understand their disease, the benefits and
burden of treatment options, and their values
and goals to preserve the autonomy of client.
MANAGE THE SYMPTOMS
- Managing the multiple symptoms commonly
experienced by the chronically ill or dying
clients remains a primary goal of palliative care
nursing.
- Ongoing clinical assessment, reassessing pain
and medication side effects, developing pain
management expertise and advocating for
change if the client does not get relief from the
prescribed regimen.
ABLE TO UNDERSTAND THE PERSONAL NEED OF
THE PATIENT
- Personal hygiene and protection from
infections are two major needs of cancer
patients.
- Prevention of pressure sore
- Nutritional need – consider the taste and
desire to have specific food in consideration.
- Catheter care
- Turning patient position frequently.
MAINTAIN A COFORTABLE AND PEACE FULL
ENVIRONMENT
- It helps to relax, promote good sleep patterns
and minimize symptoms severity.
PROMOTE SPIRITUAL COMFORT AND HOPE:
- Helps the client to make connections to their
spiritual practice or cultural community.
- Collaborates with the client own spiritual N
Pleaders and community. U
- ADemonstrate patience.
FACILITATOR R CONNECTING
L S - Making a connection
L CASE MANAGER
PROTECT AGAINST ABANDONMENT AND ISOLATION E › establishing a rapport
- IAnswer promptly,ADVOCATE
if they have doubts. S › building up trust
- AInvolving the family members in clients care. - Maintaining a connection
ASSESSMENT AND
T R › being available, spending time, sharing
MANAGEMENT EXPERT
I
SUPPORT THE GRIEVING FAMILY O secrets, sharing self, maintaining trust.
- VProvide education and information L - Breaking the connection
- EInform family members are able to get way toE › usually as a result of the patient‘s death
rest and relax
- Provide psychological support
EMPOWERING
ASSIST WITH END OF LIFE DECISION MAKING
VALUING - facilitating
› recognises patient autonomy
FACILITATE MOURNING - encouraging
- Help them to accept the lossEMPOWERING
CONNECTING
- defusing
DOINGto the loss
- Support efforts to adjust › dealing with negative feelings
FOR
- Encourage establishment of new relationship - mending
PRESERVING FINDING
- Allow to grieve
INTEGRITY MEANING › facilitating healing
- Interpret normal behavior - giving information
- Provide continuous support
- Be alert for ineffective coping. DOING FOR…
- Taking charge
› Symptom control
› Making arrangements
- Team player
› Acting as the patient’s advocate

FINDING MEANING
- Focusing on living
› helping the patient to live as fully as
possible
- Acknowledging death
› giving or reiterating bad news
› talking about death and the time left

PALLIATIVE CARE NURSING PRESERVING INTEGRITY

- Confronting own mortality
- Burnout
- Supporting Colleagues

HOPE

COMFORT

Physical Distress Physical Ease

HOPE DIM

HOPE SU

17
ATTACHMENT
 - Inadequate training of health care personnel in
symptom management & other End of life
skills.
- Inadequate standards of care
- Lack of accountability in the care of dying
patients.
- Lack of appropriate information & resources
- Lack of investment in research pertaining to
palliative & end of life care.
- There are over 135 hospice and palliative care
services in 16 states in India, concentrated in
large cities.
- There are 19 states or Union territories in which
HOPE NURTURING INTERVENTIONS IN PALLIATIVE no palliative care provision was identified.
CARE - Barriers to the development of palliative care
- Comfort include – poverty, population density,
› Assessment, psychosocial issues. geographic distances, opioid availability, work
- Attachment force development and limited national
› Be there, caring environment, promote palliative care policy.
communication
- Worth
› Explore previous experience, future wishes, PALLIATIVE CARE DEVELOPMENTS AROUND THE
enhance independence WORLD
- The estimated number of persons needing
palliative care is just over 33 million.
THE TYRANNIES OF PALLIATIVE CARE - Death also affects family members and with
(ARANDA, 2001) one to two persons shouldering the heavy daily
- Niceness routine of care, this gives a conservative figure
- Glowing testimonial of 100 million people who would benefit by the
- Depressing/Sad availability of basic palliative care.
- Passive - The rise of hospice and palliative care in its
distinctly modern guise (combining clinical
care, education, and research) is generally
traced to the late 1950s and early 1960s.
- A 1999 listing of palliative care organizations
with a global perspective(43) also includes:
CARE OF THE FAMILY › British Aid for Hospices Abroad;
- Including patient & significant others in › Hospice Education Institute; and
decision making r/t patient care. › WHO Collaborating Centre for Palliative
- Attending to their grief, worries, preparing them Cancer Care, Oxford.
for the loss - Other groups include WHO experts and
- Communicating with family facilitates to international collaborators and WHO
1. Improve planning & coping. collaborating centers in Milan, Saitama, and
2. Encourage realistic goals & autonomy. Wisconsin.
3. Reduce uncertainty. - It is estimated that hospice or palliative care
4. Maintain trust. services now exist, or are under development,
on every continent of the world, in around 100
countries. The total number of hospice or
BARRIERS IN AVAILING PALLIATIVE CARE palliative care initiatives is in excess of 8000

18
 and these include inpatient units, hospital-
based services, community-based teams, day
care centers, and other modes of delivery. ASIA PACIFIC REGION
- Protocols for the introduction of the WHO three-
step analgesic ladder were first introduced in
INTERNATIONAL ASSOCIATIONS AND INITIATIVES IN China in 1991, leading to increased opioid use
SUPPORT OF HOSPICE-PALLIATIVE CARE and greater interest in pain and palliative care.
- In Japan, cancer is the principal cause of death,
1973 accounting for about 295 000 deaths in 2000.
- International Association for the Study of Pain, - The country‘s first service for dying people was
founded Issaquah, Washington, USA organized in the Yodogwa Christian Hospital in
1973;
1976 - in 1979, the Japanese Association for Clinical
- First International Congress on the Care of the Research on Death and Dying was established;
Terminally Ill, Montreal, Canada - in 1981, the first hospice ward inside a
hospital was created;
1980 - by 1993, the Ministry of Health and Welfare
- International Hospice Institute, became had recognized palliative care units in 11
International Hospice Institute and College hospitals, with 231 beds in total
(1995) and International Association for
Hospice and Palliative Care (1999)
PALLIATIVE CARE SERVICES IN THE 14 SECTORS OF
1982 THE ASIA PACIFIC HOSPICE PALLIATIVE CARE
- World Health Organization Cancer Pain and NETWORKS
Palliative Care
Estimate
Organizations d
Estimate
1990 providing Populatio
d annual
coverage
Sectors hospice/palliativ n by
- Hospice Information Service, founded at St e care (millions)
cancer
palliative
deaths
(millions) care
Christopher‘s Hospice, London, UK services
India 49 1000 ----- -----
1998
Japan 102 127 295 482 5
- Poznan Declaration leads to the foundation of
the Eastern and Central European Palliative Malaysia 30 22 7 825 24
Task Force (1999) New
42 4 7 461 83
Zealand
Singapor
1999 e
10 4 4 237 66

- Foundation for Hospices in Sub-Saharan Africa Taiwan 28 22 32 000 5

founded in USA

- India, with one billion inhabitants, contains

2000
one-sixth of the world‘s population and is a
- Latin American Association of Palliative Care
country of striking ethnic, cultural, and religious
founded
diversity.
2001
- Around one million new cases of cancer occur
- Asia Pacific Hospice Palliative Care Network
each year; and the vast majority are incurable
founded
at diagnosis.
- An Indian Association of Palliative Care was
2002
formed in 1994 with the support of WHO and by
- UK Forum for Hospice and Palliative Care
Worldwide founded by Help the Hospices

19
 2000 there were nearly 100 palliative care - Magnesium hydroxide
initiatives across the country.
- A detailed analysis of opioid availability Appetite
problems in India shows that approximately - Prednisole
one million people experience cancer pain in
India every year. There was no official source of Bowel obstruction (when surgery not indicated)
morphine in India in the 1980s, only ‘pump- - Dimenhydrinate
priming’ supplies for specific centers and - Haloperidol
projects, so levels of morphine consumption for - Hyoscine butylbromide
pain relief were low. - Metoclopramide
- By 1997, they reached a low of just 18 kg and
per capita consumption ranked 113th among Anxiety, depression, insomnia, psychosis
131 countries around the world. - Amitryptiline
- There is evidence that governments at many
levels (national, provincial, federal, and state) Epileptic seizures
have begun to recognize the importance of pain - Diazepam
relief and palliative care through the - Lorazepam
development of officially formulated policies. - Chlorpromazine
- Palliative care has also been incorporated into - Haloperidol
several cancer control and some HIV/AIDS - Phenytoin
programs. - Sodium valproate
- Some of these policies have had real impact,
others have been ‘paper tigers’ with little effect. Diarrhea
Often, failure results from the lack of a - Codeine phosphate
comprehensive strategy, for example, omitting - Loperamide
the community system.
Gastric Protection
EXAMPLE OF A SUGGESTED ESSENTIAL DRUG LIST - Omeprazole
FOR PALLIATIVE CARE
Fluid Retention
Analgesics - Furosemide
- Non-opioids (mild pain) - Spironolactone
› Acetylsalicylic acid
› Paracetamol
Oral Candidiasis
› Ibuprofen
- Opioids (mild to moderate pain) - Cotrimoxazole
- Codene Opioids (moderate to severe pain) - Ketoconazole
› Morphine Methadone - Nystatin
- Opioid antagonist
› Naloxene Nausea and Vomiting
- Dimenhydrinate
Corticosteroids - Holoperidol
- Dexametasone - Metoclopramide
- Prednisone
- Prednisolone
- Prochlorperazine
Laxatives
- Senna
- Sodium ducosate
WHO HAS PRODUCED GUIDELINES
- Mineral oil
FOR HANDLING ANY ESSENTIAL DRUG LIST
- Lactulose

20
FOR PALLIATIVE CARE THAT WILL INCLUDE OPIOID
DRUGS
LEGAL ISSUES
- Doctors, nurses, and pharmacists should be
empowered legally to prescribe, dispense, and
administer opioids to patients in accordance
with their needs.
ACCOUNTABILITY
- Opioids must be dispensed for medical use
only, with responsibility in law.
PRESCRIPTION
- A prescription for opioids should contain at
least the following information:
› patient‘s name
› date of prescription
› drug name, dosage, strength and form,
quantity prescribed
› instructions for use
› the doctor‘s name and business address
› the doctor‘s signature
ACCESSIBILITY
- Opioids should be available in locations that
will be accessible to as many patients as
possible.
PAIN MANAGEMENT AND PALLIATIVE CARE
COMPREHENSIVE PAIN ASSESSMENT
- “Pain is whatever the experiencing person says
it is, existing whenever he/she says it does.”
(McCaffery, 1968)
› Pain is a symptom, not a diagnosis
› Believe the patient
- Onset
- Provocative or Palliative Features
- Quality
- Radiation or Related Symptoms
- Severity – intensity and effect on function
- Temporal Pattern
TOTAL PAIN COMPONENTS
21
- P: › physical symptoms or conditions
› Arthritis, constipation, bladder
spasms, headache, thrush, as well
as cancer pain
- A: › anxiety, anger, depression,
hopelessness, loneliness
- I: › interpersonal issues – family
tensions, financial issues
- N: › non acceptance of approaching
death, spiritual or existential pain
PAIN ASSESSMENT
- History and physical
- Numerical or visual analog scales
- Patient’s description of pain and experience of
pain
- Use of appropriate lab and radiologic studies
- Thorough assessment interview
PSYCHOSOCIAL-SPIRITUAL ASSESSMENT
- Meaning of the pain to patient and family
- Previous experiences with pain and coping
mechanisms
- Psychological symptoms with pain
› Fear of disease worsening
› Depression or anxiety
› Hopelessness
› Negative physician or nurse perceptions
› Adjustments in leisure activities
- Spiritual Angst or Despair
› Meaning of pain and suffering
› Retribution
› Punishment
› Spiritual cleansing
- Social and Relational Issues
› Family roles
› Physical appearance changes
› Sexual relationship issues
› Burden on family
CULTURAL ISSUES
- Know your own attitudes and beliefs
› Admire stoics or encourage sharing of pain
issues?
› What are your thoughts or beliefs about
pain meds?
› What are your thoughts about those who
abuse pain meds?
- Develop relationship with patient and family TOLERANCE
- Build trust with patient and family - Tolerance
- Assess patient’s cultural beliefs and practices › State of adaptation in which exposure to
regarding illness and treatment of pain drug induces changes that result in
decrease in the drug’s effects over time
› So, patient requires higher doses to
PAIN SCALE maintain same benefit
- Simple descriptive pain intensity scale › Therapeutic range of opioids is very wide
- 0-10 scale
- Visual Analog Scale - Analgesic tolerance is very rare
- Faces Scale › Opioid doses remain stable if disease
remains stable
› Increased opioid requirement →
worsening disease progression
DEPENDENCE
- Physical dependence ≠ addiction
› Dependence is an expected result of LT
opioid use
› Adaptation manifested by development of
a withdrawal syndrome following rapid Severe Pain
Step 3
Strong Opioids
dose reduction, abrupt cessation, (7-10 on a 10 Point +/- Non-opioids
Scale)
administration of an antagonist (naloxone), +/- Adjuvant Analgesics

or decreasing blood levels (underdose or Step 2

Mild to Moderate Pain Weak Opioids
miss doses). (4-6 on a 10 Point Scale) +/- Non-opioids
+/- Adjuvant Analgesics
› Need to safely taper drug • No more than
50% of dose/day Mild Pain Step 1
Non-Opioids
(1-3 on a 10 Point Scale)
+/- Adjuvant Analgesics

ADDICTION VS. PSEUDOADDICTION

- Opioid Addiction
WHO ANALGESIC LADDER
› Primary, chronic, neurobiologic disease, Step 1 Step 2 Step 3
with genetic, psychosocial and Paracetamol Codeine Morphine
Cocodamol Tramadol Diamorphine
environmental factors
8/500 Buprenorphine Oxycodone
› Exhibit following behaviors: NSAID DF118 Hydromorphone
• Impaired control over drug use Fentanyl
Alfentanil
• Compulsive use of drug Methadone
• Continued use despite harm
• Crave drug As with all opioids “start low and go slow”
› Risk of iatrogenic addiction is rare in Remember ABC:
patients with no past history of substance Antiemetic for the first week
abuse Breakthrough medication
Laxatives for Constipation
- Pseudoaddiction
› Behaviors are driven by inadequate - Understanding Pain: touch – healing – active
treatment of pain listening – mind shift – presence of near and
› Behaviors disappear when pain is dear ones
adequately treated - Avoiding unnecessary interventions
- Respecting ones will
- Not letting the sufferer feel underprivileged

22
- Treating and caring more through the heart
than through the mind.

23