Meeting nursing challenges in palliative care.

The care of the dying was once the domain of hospices and their community teams, and the patients were predominantly those with terminal cancer. However, the face of palliative care in New Zealand has changed markedly over the past decade, with increasing numbers of patients requiring palliative care, greater recognition of non-cancer palliative care, the establishment of acute hospital palliative care teams, and the release of the Ministry of Health's Palliative Care Strategy and, more recently, its Cancer Control Strategy. These changes, along with our aging population, have created challenges in providing the best palliative care possible to those with life limiting illness.

Palliative care recognises that cure or long-term control of disease is not possible, palliative care is thus concerned with quality rather than quantity of life. The World Health Organisation (WHO) has defined palliative care as: "The active total care of patients whose disease is not responsive to curative treatment." (1) Such total care includes the relief of pain and suffering, affirming life and regarding death as a normal process. It integrates the physical, social, psychological, emotional, intellectual, cultural and spiritual aspects of patient care and supports patients and their significant others to live as actively as possible until death. A team approach is an important aspect of palliative care in meeting the needs of patients and their families/whanau, including bereavement counselling if indicated. The New Zealand Palliative Care Strategy, recognising the WHO's definition of palliative care, states: "All people who are dying and their family/whanau who could benefit from palliative care should have timely access to quality palliative care services that are culturally appropriate and are provided in a co-ordinated way. " (2) One of the greatest challenges, therefore, is providing the necessary education, support and understanding of the needs of the patient with a life limiting illness wherever they live, as many patients will not be close to specialist palliative care services. Many will not have the opportunity to access formal hospice services either, due to the fact they live in remote areas or because they are in an institutional care environment that either cannot or does not draw on expertise from local palliative care providers. I am the nurse consultant for the Canterbury District Health Board's Hospital Palliative Care Service. The challenge within acute care is to meet the needs of increasing numbers of patients with life-limiting illness, who have significant pain, symptom and suffering issues. This working environment means I seek ways of providing nurses with the knowledge needed to give the best possible care within an institution that does not have an intrinsic philosophy of palliative care. This knowledge can then be transferred into the wider community and into the rural setting where hospice services are not available.

Nurses are often challenged by the change in focus of care from "cure" to "care" and the subsequent alteration in patient goals. Facing the reality of death is a traumatic time for a patient and their family/whanau. It can also be a traumatic time for nurses without the necessary knowledge to assess, plan, evaluate and advocate for their patients. Just because a patient can't be cured, doesn't mean we can't have a dramatic effect on their quality of life. There is always something we can do.

Three levels of palliative care

Three levels of palliative care have been described and these are important to understand, as they offer specific detail as to how palliative care can be delivered in different settings. (3) 1) A palliative approach is applicable to all patients who have life-threatening illness. It is an holistic approach to care and considers all aspects of care, not merely physical needs. The principles of such a palliative approach should be integral to the care of all palliative patients, regardless of where they are being cared for. 2) Palliative interventions focus on the treatment of symptoms experienced by people who have advanced disease, using such modalities as surgery, radiotherapy or chemotherapy, or a combination of these. Several specialists might be involved in monitoring these treatments. 3) Specialist palliative care is provided by dedicated palliative care teams of health professionals who have specialist training. Such teams offer advice and support to those caring for patients with advanced disease.

Nurses' responsiblity

As nurses, we have a responsibility to provide a palliative approach to patients, no matter where we work and to seek the necessary knowledge to provide this. A number of initiatives are in progress in Canterbury and throughout the country to provide this knowledge and support. In others areas, similar initiatives are also in place or being developed(see story on p24-25). These initiatives mean good communication networks are established, which allow health professionals to advocate for their patients and access specialist palliative care advice promptly.

A number of national initiatives are being developed. A National Palliative Care Advisory Committee is working to form an umbrella organisation to bring together all the principle interests in palliative care, enabling them to speak with one clear voice. This organisation is likely to be called Palliative Care New Zealand and will provide national leadership and advocacy, assist with policy development, to promote best practice, and provide a forum and voice for all users, providers and funders.

A palliative care nursing forum is being established to give nurses with an interest in palliative care a forum for discussion and networking. The New Zealand Hospital Palliative Care website www.hospitalpallcarenz.org.nz provides specialist knowledge to health professionals, carers, patients and families/whanau.

Every New Zealander with a life-threatening illness should receive appropriate clinical and supportive care to maintain the best possible quality of life. To meet that challenge, and the challenge posed by increasing numbers of palliative care patients, I encourage all nurses to upskill in the needs and care of patients with life limiting illness.

References

(1) World Health Organisation (WHO). (2002) National Cancer Control Programmes: Policies and Managerial Guidelines (2nd ed). Geneva: WHO.

(2) Ministry of Health. (2001) The New Zealand Palliative Care Strategy. Wellington: Ministry of Health

3) Finlay I.G & Jones, R.V.H. (1995) Definitions of Palliative Care. British Medical Journal; 311:754.

Anne Morgan, RN, MA (Applied), is the nurse consultant for the Canterbury District Health Board's Hospital Palliative Care Service.