Holistic Approach Communication and Recommendations

Introduction

Palliative care is referred to as specialised medical care for patients or individuals suffering from serious illness to provide them relief from the stress and symptoms of the illness. The goal in palliative care is to enhance the quality of life for the patient as well as their family members. In this essay, the palliative care for Mr D is to be discussed who is 74 years old suffering from metastasised oral cancer. The way organisational, cultural and sociological factors influenced his palliative care is to be explained. The holistic care delivered and its efficiency for Mr D is to be explored. Thereafter, the way communication is made in end-of-life care is to be discussed. Further, recommendations are to be made regarding the way improvement is to be accomplished in the provided palliative care.

Case Study

The NMC Code of Practise mentions that personal identity of the patients is to be safely managed and confidentiality for their care is to be established to ensure them privacy and safety (NMC, 2018). Thus, the pseudonym Mr D is used to indicate the patient so that his privacy and confidentiality can be managed. Mr D is currently suffering from end stage metastasised oral cancer who is 74 years old and has two daughters that live in other cities but currently are present to support their father’s condition. He has smoked cigarettes and chewed tobacco from the age of 15 and was detected with oral cancer four years back which progressed rapidly despite of treatment resulting in extensive tissue necrosis. The necrosis caused loss of his teeth and tongue through surgery which led his unable to produce effective speech and difficult to swallow solid food.

Mr D also suffered severe facial disfigurement and facial pain which progressed each day. He was provided methadone initially orally but later through subcutaneous infusion as well as administered haloperidol for vomiting and nausea and lorazepam for anxiety. He was also provided oxygen through nasal cannula and fan to gently blow on his face. The refusal to continue any chemotherapy or others was made by the patient which though was not supported by the family and physicians was respected on behalf of the patient as D mentioned intense pain through the therapy and afterwards. Since D’s pain was unbearable and could not be resolved through all palliative measures, thus palliative sedation was recommended which was compassionate and humane approach for him. He was compassionately cared and midazolam of 4mg (each 30-60 min with 0.5mg/l after each bolus) was administered for sedation as asked and approved through informed consent from the patient and their family members. No artificial respiratory support or intubation for food administration was provided due to refusal from the family and patient. The support was provided for comfortable end-of-life care to Mr D as asked by him and the family.

Organisational, cultural and social factors influencing Palliative care

The organisational factors such as safety culture, staffing skills, policies and rules and others generally influence palliative care delivery to the patients (Bekelman et al., 2016). The presence of effective safety culture in the organisation influences good palliative care delivery because it ensures protection of harm of the patient in the end-of care which makes them feel valued in care (Mallon et al., 2021). In caring for Mr D, the safety culture was effectively maintained due to which adequate protection and safe palliative care was able to be delivered to the patients with no complaints of safety issue raised from the patient or their family members. As argued by Paudel et al. (2015), the lack of well-developed protocols and policies for the establishment of palliative approach in healthcare organisations hinder the quality of end-of-life support to the patients. This is because unsystematic protocol and lack of well-maintained policies of palliative care in the organisation leads the healthcare staff and physicians remain confused and act inappropriately to deliver palliative support to the patient. However, in case of D, the organisation has well-framed and systematic protocols to be followed for palliative care delivery which was abided by the healthcare staff due to which effective palliative support without hindrance was able to be provided to D.

The staffing skills is one of the organisational factors that influence palliative care delivery because the level of skill and knowledge regarding palliative care delivery by the staff determines the efficiency with which required palliative support is to be provided to the patient to ensure their enhanced quality health (Dudley et al., 2018). In case of D, the healthcare staff involved in delivering palliative support were found to be qualified and adequately skilled due to which the care was able to be delivered as per the need of the patient. However, some staff may be lacking effective skills as too much preference of care idea from the patient was supported instead of exact medical care to be provided due to which care in the best interest of the patient is somewhat hindered. As asserted by Kagan et al. (2020), organisational culture influences palliative care delivery as it indicates the way teamwork is to be performed within the organisation and professionals to be involved so that it leads to successful end-of-life healthcare outcomes for the patient. This is because organisational cultures influence the values, expectations and practices within the organisation which guides the team members in healthcare to act accordingly in delivering quality palliative care. The organisation caring for Mr D supports interdisciplinary team working culture due to which professional from different disciplines such as dieticians, medical oncologist, neck and head clinical nurse specialist, restorative dentistry consultant and other are involved in planning his advanced palliative care. The culture helped to create a team working environment for delivering enhanced palliative care from experts to Mr D for his better health and well-being.

The cultural competency and sensitivity are cultural factors that influences palliative care delivery. This is because presence of cultural competency among healthcare staff ensures they have knowledge of the cultural beliefs and values of the patients from different cultural background which makes the patients feel their cultural beliefs, customs and others are valued by the staff. It creates an enhanced honest relationship with the patients to make them effectively comply with the care provided by the staffs during the palliative phase (Pentaris and Thomsen, 2020). Moreover, effective cultural sensitivity in palliative care environment ensures creating a trustful and comfortable care environment for the patients during suffering from intense health issues (Bhat et al., 2015). As argued by Mazanec and Panke (2015), lack of effective cultural competency and sensitivity in palliative care leads the patients to feel dissatisfied with care and lack sense of interpersonal control in the care processes. This is because their cultural customs, values and others in cultural insensitive and incompetency care environments are not valued which makes them disrespected and uncomfortable to comply and accept care.

In case of Mr D, who was seen to belong from Jewish culture was ensured culturally competent and sensitive care environment by the nurses in palliative care. This is evident as in Jewish culture, the treatment which are not potentially curative and causes pain to the patients in palliative condition can be refused by the patients (Cohen et al., 2018). In case of Mr D, his refusal to accept further treatment like chemotherapy and others as they were causing pain was accepted proving the palliative care was provided in culturally sensitive and competent way by the nurses. As asserted by Schrank et al., (2017), accessibility of cultural services in palliative care influences its quality delivery of support to the patient. This is because accessible of cultural services in end-of-life condition ensure cultural willingness and norms of the patients in palliative care to be valued which makes them feel respected in care. However, it is argued that Kolmar and Kamal (2018) lack of accessibility of cultural services in palliative care shows disrespect towards the cultural needs and norms of the patients which makes them feel lack of attention in care by the healthcare staff. In case of Mr D, accessibility of cultural services is appropriately maintained as though Christianity is followed by the nurses caring for him, they arrange Jewish hospice services as demanded by the patient during the palliative care.

The social factor such as economic condition influences quality of delivery of palliative care. This is because the amount of finances able to be spent by the patients and their family determines the level of palliative care treatments to be provided to the individual as some of the care involves huge cost (Lal et al., 2016; May, P., Garrido et al., 2016). In case of Mr D, he was found to be economically stable and financially supported by his daughters which helped in providing the best palliative care available for him without any issue of financial constraints been raised. As asserted by Kumar et al., (2017), timely healthcare access is one of the social factors that influence efficiency of palliative care to be delivered to the patients. This is because quality timely palliative healthcare leads to limit the pain and suffering of the patients from their serious illness which may be their end-of-life condition and ensures the enhanced well-being. In case of D, timely and quality healthcare access was approved for him in the palliative condition due to which he was found to be satisfied with the care delivered and no complaints was made from the family members regarding efficiency of palliative care delivery.

The presence of adequate education and health awareness is another social factor that influences effectively delivery of palliative care. This is patients with lower education and health awareness are seen to access late palliative care during which effective support though provided to the patients is unable to resolve or manage their serious illness which leads them to face worsened health condition (Hannon et al., 2016). In case of D, it was seen that he had adequate education and health awareness regarding oral cancer due to which he opted for palliative care at the earliest to lead a comfortable life in the end days. The perspective of death and dying in another social factor influencing quality of palliative care. This is evident as if the patient expresses easy acceptance of death or dying from the serious illness, then it can be determined that effective quality palliative care is provided to meet the needs of the patient in the end days which reflected them to be peaceful in accepting death (Fadhil et al., 2017). In case of D, all his needs during the palliative care was effectively abided and maintained by the nurses which helped to lead him to be comfortable and have a positive perspective regarding death and dying from cancer.

Holistic care delivery in Palliative care

A holistic care approach is referred to the support that is provided to the patients by considering the individual’s needs as a whole and not only meeting the mental health needs of the patient. The efficient holistic care approach includes meeting the emotional, physical, spiritual and social needs of the patient for promoting their well-being (Ventegodt et al., 2016). As apparent from the case study, the physical needs of Mr D required to be fulfilled through palliative care are reduction of pain, support for having food, breathing and ability to communicate. In order to reduce the pain, palliative sedation process by using midazolam for D was used. This acted as strong holistic care delivery as midazolam has shorter half-life and is clinically evident to be used as sedative pharmacotherapy in end-of-life condition (Prommer, 2020). The use of propofol would have been valuable than midazolam but is costly and limited to be used outside intensive care units (ICU) (Sulistio et al., 2020). Mr D was not in ICU which ensured the use of midazolam was effective holistic approach in the palliative care for him to reduce pain.

The restorative dentistry consultant was involved for Mr D to restore his dentine with temporary dentures which is effective to allow the patient to chew food and have better facial structure (Jawad et al., 2015). Thus, the inclusion of restoration of dentures was strong part of the holistic care delivered to Mr D as it allowed him to have minimum efficiency in chewing food which was entirely lost before. Further, the involvement of dietician was effective holistic care approach for Mr D as is helped in planning the effective diet to be followed to ensure enhanced nutrition is provided to him in last days of his life without any hindrance to make him feel enhanced well-being. One of the weakness in the holistic care for Mr D was accepting his willingness to end chemotherapy and other treatment irrespective being unapproved by family members. This is because chemotherapy though causes pain leads to destroy cancerous cells to allow increased life to the patient (Chan et al., 2016). Thus, avoiding ongoing of the treatment may have led to support early dismissal of Mr D along with increased pain out of progressing oral cancer by the nurses.

The presence of anxiety is common in the end-of-life condition or palliative care as it is the natural response by the patient to complex uncertainty of presence of limited life or death (Bužgová et al., 2015). However, it is considered a clinical issue in patients. Thus, lorazepam is provided to Mr D which is effective in improving his emotional condition regarding anxiety. This was strong part of holistic care as lorazepam acts to bind with benzodiazepine receptors in the brain acting to increase the release of a calming chemical known as gamma-amino-butyric-acid (GABA) in the brain effective to reduce stress and anxiety (Hui et al., 2017). Thus, emotional need of the patient is fulfilled through the palliative care indicating enhanced holistic support is maintained. The involvement of medical oncologist and head and neck nurse specialist in palliative support for Mr D was effective strong action in delivering him holistic care. This is because they are experts in determining the nature and measures of care and palliative support for physical well-being of patients with oral cancer is to be maintained (Tsubura-Okubo et al., 2021). Further, the oxygen support and medication to reduce vomiting was strong holistic care in palliative support for Mr D as they helped him in executing enhanced breathing and less hindrance in having food.

One of the challenges faced in delivering holistic care to Mr D was inability in meeting his social need of allowing his daughters to stay with him at the hospital and permitting friends and other family members to visit him at any time he wishes. This is because in the Covid-19 situation, the visiting hours and members are been limited for better safety of the patients and others in healthcare organisations as it assists in maintaining social distancing and other protocols to avoid the spread of the virus (Antommaria et al., 2021). Thus, social need of Mr D was unable to be maintained during the palliative care leading hindered holistic care been provided to him as meeting social needs of individual in holistic support is important. The spiritual need of Mr D was met by allowing Jewish hospice support services to him as demanded. However, the threat faced in delivering the services to develop holistic care approach for Mr D is development of hindered religious-based faith that could challenge the clinical team in making the patient approve in accepting certain care. For instance, in Jewish culture, meat developed by slaughtering animals by the process of Shechita are allowed to be consumed (Zivotofsky, 2012). In this condition, the failure of providing such meat to Mr D on being influenced by Jewish hospice care may lead him to create non-compliance in accepting food from nurses which would further deteriorate his health.

Communication in Palliative care

In the end-of-life care or palliative care, the communication at the patient level is to execute in empathetic and compassionate manner by the physicians and nurses. This is because it makes the patients feel the professionals understand their pain of serious illness and adequately willing to cooperate with them in going through the pain by feeling as own which makes them trust the carer and comply in care (Goldsmith and Ragan, 2017). However, failure to communication with patients in palliative care through compassion and empathy leads them to be anxious and show conflict in accepting care and adhering to medication (Sinclair et al., 2017). In case of Mr D, effective empathy and compassion are expressed while communicating with him to make him develop trust over the nurses and comply in care to support nurses to delivery quality care for his well-being. In order to communicate at the patient level around palliative care, the nurses are to actively listen to the needs of the patients and reflect on the communication. This is because active listening by the nurses in palliative care leads them to show value to the patients and determine the needs to be fulfilled. Moreover, the active reflection of communication makes the nurses in palliative care aware way their interaction to be improved further for offering better compassion and support through the interaction to the end-of-life patients like Mr D (Brito-Pons and Librada-Flores, 2018).

The communication around palliative care for the patients are to be made by nurses in non-judgemental manner. This is because it helps to ensure dignity of the patients and makes them feel to have voce in deciding their care (Du Plessis, 2016). Thus, in case of Mr D, the communication was made in non-judgemental manner without considering way his cultural or social attitude may influence his body language during communication. In palliative care, for making effective communication at the organisational level, formal interaction is to be supported where detailed health record of the patient is present to shared among all members of the interdisciplinary team. This is going to allow each team members regarding the way they are further executing their role to avoid duplication of care and better well-being of the patient in the end-of-life days (Mélin et al., 2020). In case of Mr D, his record was always remained updated to be only assessed and reviewed by inter-disciplinary team member responsible in his palliative care to ensure his privacy is maintained while adequate patient information is shared among professionals as need to ensure his good health. At the organisational level, effective internal interaction is to be established between professionals involved in delivering palliative care to the patient. This is because it helps the professionals to discuss ideas regarding the way each can modify their role and involve more intricately in the care of the patients that would improve their well-being in the last few days of their life (Arrieira et al., 2018). Thus, effective written, as well as verbal communication, was allowed between professionals at the organisational level who are involved in caring for patients like Mr D.

Improvement needed in Palliative care

One of the actions to be improved in the palliative care for Mr D is influencing him to continue the treatment (chemotherapy) for oral cancer even though it is painful as the physicians as well as his family members mentioned to have hope for his better well-being and increased life. He is to be influenced to understand the way the experienced pain in chemotherapy could be controlled through physiotherapy and other physical therapies for allowing him to be able to live a better life (Goel et al., 2020). The NMC Code mentions delivering care by meeting the needs of the patients and act in their best interest (NMC, 2018). Thus, effective approval from Mr D is required to continue the treatment because continuation of chemotherapy would ensure slightly longer life for D but avoid death which is imminent due to metastasised oral cancer. The other improvement require is measuring the effectiveness of the palliative care measures taken for D while comparing them with other measures. This is because it would help to determine if the mentioned palliative care measures are best and what extent effective in improving well-being of the patient (Kawashita et al., 2019).

Conclusion

The above discussion mentions that Mr D is suffering from last stage oral cancer that has metastasised in the different parts of the body for which he is receiving palliative care. In palliative care, palliative sedation was approved for the patient by accessing informed consent from him and his family members. The organisation factors influencing the enhanced delivery of palliative care for Mr D include highly skilled staff, inter-disciplinary support working culture and well-develop palliative care delivery protocol. The social factors such as enhanced economic condition, education and others also influence positive palliative care for Mr D. The presence of cultural competence, sensitivity and accessibility of spiritual care services ensure good palliative care for Mr D. The strength of the holistic care was use of effective pharmacotherapy and inter-disciplinary care team in delivering palliative care for Mr D that meet all his social, emotional, spiritual and physical needs. However, the weakness in holistic care lack of acceptance of chemotherapy support for better physical health of Mr D. The presence of empathetic, compassionate, structural and other factors of communication at patient and organisational level led to enhanced palliative care delivery to Mr D.

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